During a physical assessment the client asks the nurse repeatedly, "Is everything ok?" The nurse believes this client is demonstrating:
1. A poor self-concept.
2. Inappropriate affect.
3. Confusion.
4. Anxiety.
4
Rationale 1: A client's level of anxiety is reflected in speech, body language, and facial expressions. Repeatedly asking if "everything is ok" could be evidence of worry about the outcome of the examination.
Rationale 2: Evidence of a poor self-concept would include poor personal hygiene practices.
Rationale 3: An inappropriate affect would be demonstrated if the client responding inappropriately to a situation, such as laughter when discussing the death of a pet.
Rationale 4: Confusion would be demonstrated by a client who is not oriented to person, place, or time.
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