A client with chronic renal failure is admited with a heart rate of 122 beats/minute; a respiratory rate of 32 breaths/minute, a blood pressure of 190/110 mm Hg, neck vein distention, and bibasilar crackles. Which nursing diagnosis takes highest priority for this client? Select one answer

Fear

Toileting self-care deficit

Excess ﬂuid volume

Urinary retention

Answer and Explanation

The Correct Answer is A

Choice A reason: Fear is a nursing diagnosis that indicates a problem with the client’s emotional response to a perceived threat or danger. It can be caused by factors such as uncertainty, lack of control, or loss of function. It can result in symptoms such as anxiety, restlessness, or palpitations. The client may experience fear related to their chronic renal failure and its complications, but it is not the highest priority nursing diagnosis, as it is not directly aﬀecting their physical health or safety. Therefore, this choice is incorrect.

Choice B reason: Toileting self-care deficit is a nursing diagnosis that indicates a problem with the client’s ability to perform or complete activities related to urination or defecation. It can be caused by factors such as physical impairment, cognitive impairment, or environmental barriers. It can result in symptoms such as incontinence, constipation, or skin breakdown. The client may have a toileting self-care deficit related to their chronic renal failure and its eﬀects on their urinary function, but it is not the highest priority nursing diagnosis, as it is not immediately life-threatening. Therefore, this choice is incorrect.

Choice C reason: Excess ﬂuid volume is a nursing diagnosis that indicates a problem with the retention of water and sodium in the body. It can be caused by factors such as renal failure, heart failure, or liver cirrhosis. It can result in symptoms such as edema, hypertension, tachycardia, dyspnea, or crackles. The client’s vital signs and physical findings suggest that they have excess ﬂuid volume, which is the highest priority nursing diagnosis, as it can lead to pulmonary edema, cardiac arrhythmias, or stroke if not treated promptly. Therefore, this choice is correct.

Choice D reason: Urinary retention is a nursing diagnosis that indicates a problem with the inability to empty the bladder completely or at all. It can be caused by factors such as obstruction, infection, or medication. It can result in symptoms such as difficulty or pain in urinating, frequent or urgent urination, or abdominal distension. The client may have urinary retention related to their chronic renal failure and its eﬀects on their bladder function, but it is not the highest priority nursing diagnosis, as it is not directly causing their ﬂuid overload or cardiovascular compromise. Therefore, this choice is incorrect.

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Correct Answer is D

Explanation

Choice A reason: “I am sure they are all beef hot dogs. Would you like me to get a substitution from the kitchen?” is not the best response by the PN. This response shows false reassurance, which is a communication technique that involves minimizing or dismissing the other person’s feelings or situation. It also shows assumption, which is a communication barrier that involves making judgments or guesses about what the other person thinks or feels. It does not respect the client’s dietary preferences, and may sound patronizing or condescending. Therefore, this choice is incorrect.

Choice B reason: “I don’t understand why that should make a diﬀerence.” is not the best response by the PN. This response shows lack of knowledge, which is a communication barrier that involves being unaware or ignorant of the other person’s culture, beliefs, or values. It also shows indiﬀerence, which is a communication barrier that involves showing no interest or concern for the other person’s feelings or situation. It does not respect the client’s dietary preferences, and may sound rude or oﬀensive. Therefore, this choice is incorrect.

Choice C reason: “So you don’t want anything to eat, then?” is not the best response by the PN. This response shows closed-ended questioning, which is a communication technique that involves asking questions that require a yes or no answer or a specific piece of information. It also shows sarcasm, which is a communication barrier that involves using irony or mockery to hurt or ridicule the other person. It does not respect the client’s dietary preferences, and may sound hostile or aggressive. Therefore, this choice is incorrect.

Choice D reason: “I respect your dietary preferences. Let me see what else I can oﬀer you.” is the best response by the PN. This response shows respect, which is a value or attitude that involves showing consideration, appreciation, and recognition for the other person as a unique and holistic person. It also shows support, which is a communication technique that involves providing emotional or practical assistance to the other person, and helping them cope with their situation or problem. It respects the client’s dietary preferences, and shows that the PN is caring, helpful, and empathetic. Therefore, this choice is correct.

A. Approximated wound edges B. Yellow, purulent drainage C. Pink granulation tissue D. Sutures in place

Correct Answer is A

Explanation

Choice A reason: This is incorrect because it shows that the wound is healing well. Approximated wound edges mean that the edges are close together and aligned.

Choice B reason: This is correct because it shows that the wound is infected. Yellow, purulent drainage means that the wound has pus, which is a sign of inﬂammation and bacterial growth.

Choice C reason: This is incorrect because it shows that the wound is healing well. Pink granulation tissue means that the wound has new blood vessels and connective tissue, which fill the wound space and promote healing.

Choice D reason: This is incorrect because it shows that the wound is stable. Sutures in place mean that the wound has been closed with stitches, which hold the edges together and prevent bleeding.

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A client with chronic renal failure is admited with a heart rate of 122 beats/minute; a respiratory rate of 32 breaths/minute, a blood pressure of 190/110 mm Hg, neck vein distention, and bibasilar crackles. Which nursing diagnosis takes highest priority for this client? Select one answer

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client of the Islamic faith refuses to eat a hot dog on his tray because he is afraid that it may contain pork products. Which of the following is the best response by the Practical Nurse (PN)?

Correct Answer is D

Explanation

The nurse is changing a client’s dressing. Which observation warrants immediate physician notification?

Correct Answer is A

Explanation

A female client who is experiencing disordered thinking about food being poisoned is admited to the mental health unit. The nurse should use which communication technique to encourage the client to eat dinner? Select one answer

A patient roughly asks the nurse to bring him some ice cream. An assertive response by the nurse is:

The husband of a client who has a Sengstaken-Blakemore tube states to the nurse, “I thought having this tube down her nose the first time would convince my wife to quit drinking.” The nurse should make which response to the client’s husband? Select one answer

In what step of the nursing process do the client and the nurse develop the goals? (Select all that apply)

A Practical Nurse (PN) is planning on leaving the room of a patient with a tracheotomy. The PN ensures that the client has which of the following means of communication before leaving the room?

The Practical Nurse recognizes the communication technique of receiving information and examining responses to