Although the client denies pain, the Practical Nurse (PN) observes the client is breathing rapidly with clenched fists and is grimacing. The PN’s best response to his observations would be: * Select one answer

“Where do you hurt?”

"I am glad you are feeling beter and have no discomfort.”

"What you are saying and what I am observing don’t seem to match.”

"It makes me uncomfortable when you are not honest with me.”

Answer and Explanation

The Correct Answer is C

Choice A reason: “Where do you hurt?” is not the best response to the PN’s observations. 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 confrontation, which is a communication technique that involves challenging or opposing the other person’s statements or behaviors. It may make the client feel defensive, pressured, or misunderstood, and may discourage further communication. Therefore, this choice is incorrect.

Choice B reason: "I am glad you are feeling beter and have no discomfort.” is not the best response to the PN’s observations. 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 inconsistency, which is a communication barrier that involves giving contradictory or conﬂicting messages. It may make the client feel confused, ignored, or invalidated, and may undermine the trust or rapport between the client and the PN. Therefore, this choice is incorrect.

Choice C reason: "What you are saying and what I am observing don’t seem to match.” is the best response to the PN’s observations. This response shows reﬂection, which is a communication technique that involves restating or paraphrasing what the client has said to show understanding and clarify meaning. It also shows congruence, which is a communication skill that involves using consistent verbal and nonverbal cues to reinforce the message and avoid confusion or misunderstanding. It helps the client to recognize and explore their own feelings or thoughts, and shows that the PN is atentive, respectful, and empathetic. Therefore, this choice is correct.

Choice D reason: "It makes me uncomfortable when you are not honest with me.” is not the best response to the PN’s observations. This response shows self-disclosure, which is a communication technique that involves sharing personal information or feelings with the other person. It also shows accusation, which is a communication barrier that involves blaming or criticizing the other person for their statements or behaviors. It may make the client feel

guilty, ashamed, or angry, and may damage the relationship or communication between the client and the PN. Therefore, this choice is incorrect.

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Correct Answer is A

Explanation

Choice A reason: This is incorrect because it shows that the nurse is not using a systematic and evidence-based approach to care. The nurse’s notes are a form of documentation, not a source of planning.

Choice B reason: This is correct because it shows that the nurse is using a systematic and evidence-based approach to care. The nursing diagnosis is a clinical judgment that identifies the client’s actual or potential health problems or needs and provides the basis for selecting appropriate interventions.

Choice C reason: This is incorrect because it shows that the nurse is not using a holistic and individualized approach to care. The doctor’s orders are a form of prescription, not a source of planning.

Choice D reason: This is incorrect because it shows that the nurse is confusing the outcome with the process. The care plan is a written document that outlines the goals, interventions, and evaluation of care, not a source of planning.

A. Client’s problem B. Care plan C. Evaluation D. Assessment

Correct Answer is ["D"]

Explanation

Choice A reason: Needs medical intervention is not the major diﬀerence between the two diagnoses. Both diagnoses may require medical intervention, depending on the severity and cause of the vomiting and the nutritional deficiency. Medical intervention is not a criterion for distinguishing between diﬀerent types of nursing diagnoses.

Therefore, this choice is incorrect.

Choice B reason: Needs no defined nursing interventions is not the major diﬀerence between the two diagnoses. Both diagnoses need defined nursing interventions, such as monitoring, teaching, counseling, or providing ﬂuids and electrolytes. Nursing interventions are essential for addressing any nursing diagnosis, whether actual or potential.

Therefore, this choice is incorrect.

Choice C reason: Will not need to be evaluated is not the major diﬀerence between the two diagnoses. Both diagnoses need to be evaluated, which involves measuring the outcomes and determining whether the interventions were eﬀective in resolving or preventing the problem. Evaluation is a vital step of the nursing process for any nursing diagnosis, whether actual or potential. Therefore, this choice is incorrect.

Choice D reason: Reﬂects a problem that does not yet exist is the major diﬀerence between the two diagnoses. Diagnosis #1 is an actual nursing diagnosis, which reﬂects a problem that exists at the present time and has signs and symptoms that can be observed or measured. Diagnosis #2 is a risk for nursing diagnosis, which reﬂects a problem that does not exist at the present time but may develop in the future if preventive measures are not taken.

Therefore, this choice is correct.

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Although the client denies pain, the Practical Nurse (PN) observes the client is breathing rapidly with clenched fists and is grimacing. The PN’s best response to his observations would be: * Select one answer

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The basis for designing and selecting nursing interventions to meet client needs is the:

Correct Answer is A

Explanation

The Practical Nurse (PN) uses the “risk for” nursing diagnoses as identified from the: Select all that apply

Correct Answer is ["D"]

Explanation

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