When a problem is suspected, but lacks enough data to support it, the nursing diagnosis is:

A wellness nursing diagnosis

A syndrome nursing diagnosis

A ‘risk for’ nursing diagnosis

An actual nursing diagnosis

Answer and Explanation

The Correct Answer is C

Choice A reason: This is incorrect because it shows that the problem is not suspected, but rather the client has a desire to improve or maintain a level of health. A wellness nursing diagnosis describes a potential or actual health state that can be enhanced.

Choice B reason: This is incorrect because it shows that the problem is not suspected, but rather the client has a cluster of related problems that are associated with a specific situation or event. A syndrome nursing diagnosis describes a patern of responses that are linked by a common cause.

Choice C reason: This is correct because it shows that the problem is suspected, but lacks enough data to support it. A ‘risk for’ nursing diagnosis describes a potential problem that may occur if certain risk factors are present.

Choice D reason: This is incorrect because it shows that the problem is not suspected, but rather the client has signs and symptoms that indicate an actual health issue. An actual nursing diagnosis describes a current problem that has been validated by data.

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Correct Answer is D

Explanation

Choice A reason: Restating is a therapeutic communication technique that involves repeating or paraphrasing what the client has said to show understanding and clarify meaning. It is not an appropriate intervention to provide comfort during a painful procedure, especially when the client does not speak English. Therefore, this choice is incorrect.

Choice B reason: Listening is a therapeutic communication technique that involves paying atention and showing interest in what the client has to say. It is an important skill for building rapport and trust, but it is not an eﬀective intervention to provide comfort during a painful procedure, especially when the client does not speak English.

Therefore, this choice is incorrect.

Choice C reason: Silence is a therapeutic communication technique that involves allowing pauses or gaps in the conversation to give the client time to think, reﬂect, or express emotions. It can be useful in some situations, but it is not a sufficient intervention to provide comfort during a painful procedure, especially when the client does not speak English. Therefore, this choice is incorrect.

Choice D reason: Touch is a nonverbal communication technique that involves using physical contact to convey empathy, support, or reassurance. It can be a powerful intervention to provide comfort during a painful procedure, as long as it is done with respect, consent, and cultural sensitivity. It can also transcend language barriers and communicate caring and compassion. Therefore, this choice is correct.

A. Select one answer B. “I am sure they are all beef hot dogs. Would you like me to get a substitution from the kitchen?” C. “I don’t understand why that should make a diﬀerence.” D. “So you don’t want anything to eat, then?”

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.

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When a problem is suspected, but lacks enough data to support it, the nursing diagnosis is:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The client does not speak English; therefore, the Practical Nurse (PN) cannot use words to provide comfort during a painful procedure. The PN selects another intervention to provide comfort, which is: * Select one answer

Correct Answer is D

Explanation

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

A nurse who is assigned to care for six clients is administering a tube feeding to a client when another client spills breakfast coﬀee on her chest and abdomen. What actions by the nurse are best? (Select all that apply)

When writing expected outcomes, the Practical Nurse (PN) should adhere to accepted criteria, such as which of the following? (Select all that apply)

During the planning step of the nursing process, the nurse performs which activity? Select one answer

The Practical Nurse (PN) is caring for a client with dementia and memory loss. Which of the following communication techniques would be most eﬀective? (Select all that apply)

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

During a physical examination, the Practical Nurse (PN) discovers that the client demonstrates signs of ﬂushed, dry, hot skin; dry oral mucus membranes; and temperature elevation. The PN will treat these data as the basis of a nursing diagnosis plan, as they represent:

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

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