A client is hospitalized with Pneumocystis carinii pneumonia. The nurse notes that the client has had no visitors, seems withdrawn, avoids eye contact and refuses to take part in conversation. In a loud, angry voice the client demands that the nurse leave the room. The nurse formulates a diagnosis of Social isolation. Based on this diagnosis, what is an appropriate goal of care for the client? Select one answer
Identifying one way to increase social interaction
Returning a demonstration of measures that can increase independence
Identifying at least one factor contributing to altered sexuality paterns
Reporting increased adaptation to changes in health status
The Correct Answer is D
Choice A reason: Symptoms are subjective data that are reported by the client, such as pain, nausea, or fatigue. They are not observable or measurable by the nurse, and they may vary depending on the client’s perception or expression. The data that the PN discovered are not symptoms, but objective data that are observed or measured by the nurse, such as skin condition, oral mucus membranes, and temperature. Therefore, this choice is incorrect.
Choice B reason: Urinary retention is a condition in which the client is unable to empty the bladder completely or at all. It can cause symptoms such as difficulty or pain in urinating, frequent or urgent urination, or abdominal distension. It can also lead to complications such as infection, kidney damage, or bladder rupture. The data that the PN discovered are not related to urinary retention, but to dehydration or fever. Therefore, this choice is incorrect.
Choice C reason: Signs of fluid overload are objective data that indicate excess fluid in the body, such as edema, weight gain, crackles in the lungs, or elevated blood pressure. They can result from conditions such as heart failure,
kidney failure, or liver cirrhosis. The data that the PN discovered are not signs of fluid overload, but signs of fluid deficit or heat stroke. Therefore, this choice is incorrect.
Choice D reason: Data clustering is a process of grouping related data together to form a meaningful patern that can support a nursing diagnosis. It can help the nurse to identify the client’s problems, needs, or risks, and to prioritize and plan interventions accordingly. The data that the PN discovered are an example of data clustering, as they represent a patern of signs that indicate a possible problem such as dehydration or fever. Therefore, this choice is correct.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Gives the same message to the patient verbally and nonverbally is an example of using assertive communication, not a sign of needing further teaching on it. Assertive communication is a communication style that involves expressing one’s thoughts, feelings, and needs in a clear, respectful, and confident manner. It also involves using congruent verbal and nonverbal cues, such as eye contact, tone of voice, and body language, to reinforce the message and avoid confusion or misunderstanding. Therefore, this choice is incorrect.
Choice B reason: Speaks firmly and positively is an example of using assertive communication, not a sign of needing further teaching on it. Assertive communication is a communication style that involves expressing one’s thoughts, feelings, and needs in a clear, respectful, and confident manner. It also involves using firm and positive language, such as “I” statements, active verbs, and constructive feedback, to convey the message and avoid aggression or passivity. Therefore, this choice is incorrect.
Choice C reason: Is unapologetic is an example of using assertive communication, not a sign of needing further teaching on it. Assertive communication is a communication style that involves expressing one’s thoughts, feelings,
and needs in a clear, respectful, and confident manner. It also involves being unapologetic for one’s opinions, beliefs, or values, as long as they do not harm or disrespect others. It does not mean being rude or arrogant, but rather being honest and authentic. Therefore, this choice is incorrect.
Choice D reason: Agrees to do whatever the patient requests is a sign of needing further teaching on using assertive communication, not an example of it. Agreeing to do whatever the patient requests is a communication style that involves suppressing one’s thoughts, feelings, and needs in order to please or avoid conflict with others. It is a form of passive communication, which can lead to resentment, frustration, or loss of self-esteem. It can also compromise the quality of care or the safety of the patient or the nurse. Therefore, this choice is correct.
Correct Answer is ["B"]
Explanation
Choice A reason: Maslow’s hierarchy of needs is a framework for prioritizing human needs, but it is not an organized approach for performing a physical examination. A physical examination should be systematic and comprehensive, not based on subjective preferences or assumptions. Therefore, this choice is incorrect.
Choice B reason: A head-to-toe assessment is an organized approach for performing a physical examination that covers all the major body systems and regions. It allows the nurse to identify any abnormalities or changes in the client’s health status and to document the findings in a consistent manner. Therefore, this choice is correct.
Choice C reason: Subjective data collection is the process of obtaining information from the client about their symptoms, feelings, beliefs, and preferences. It is an important part of the nursing assessment, but it is not an organized approach for performing a physical examination. A physical examination requires objective data collection, which involves observing, measuring, and testing the client’s physical signs. Therefore, this choice is incorrect.
Choice D reason: Review of systems is an organized approach for performing a physical examination that focuses on each body system separately and asks specific questions related to its function and problems. It helps the nurse to elicit relevant information from the client and to detect any abnormalities or deviations from normal. Therefore, this choice is correct.
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