A client diagnosed with chronic kidney disease is completing an exchange during peritoneal dialysis. The nurse observes that the peritoneal fluid is draining slowly and that the client’s abdomen is increasing in girth. What is the nurse’s most appropriate action?

Advance the catheter 2 to 4 cm further into the peritoneal cavity

Infuse 50 mL of additional dialysate

Aspirate from the catheter using a 60-mL syringe

Reposition the client to facilitate drainage

Answer and Explanation

The Correct Answer is D

Choice A reason: Advancing the catheter further risks perforation or malposition, potentially damaging peritoneal tissues or organs. Slow drainage is often due to positional obstruction or constipation, not catheter depth. This invasive action requires medical orders and imaging confirmation, making it inappropriate as a first step in addressing slow drainage.

Choice B reason: Infusing additional dialysate worsens abdominal distension and does not address slow drainage. It may increase intra-abdominal pressure, causing discomfort or complications like hernia. The issue is outflow obstruction, not insufficient dialysate, so adding more fluid is counterproductive and could exacerbate the client’s condition.

Choice C reason: Aspirating with a syringe is not standard practice and risks introducing infection or damaging the catheter. It does not address underlying causes like positional obstruction or fibrin clots. Medical evaluation or specialized interventions like heparin instillation are needed for persistent drainage issues, making this action inappropriate.

Choice D reason: Repositioning the client facilitates drainage by relieving positional obstructions, such as catheter kinking or omental wrapping, common in peritoneal dialysis. Changing positions (e.g., side-lying or sitting) promotes gravity-assisted flow, reducing abdominal girth and improving exchange efficiency. This non-invasive action is the safest and most effective initial step.

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Correct Answer is C

Explanation

Choice A reason: A calm expression does not reliably indicate low anxiety, as individuals may mask emotions due to cultural norms or coping mechanisms. Nonverbal cues are subjective and context-dependent, and physiological signs like heart rate or cortisol levels are more accurate indicators of anxiety than facial expressions alone.

Choice B reason: Eye contact is not a universal measure of attentiveness, as cultural norms vary (e.g., some cultures avoid eye contact to show respect). Individual factors like anxiety or neurodiversity can also affect eye contact, making it an unreliable indicator of engagement without considering context and patient background.

Choice C reason: Nonverbal communication, such as gestures or expressions, varies widely across cultures and individuals. For example, nodding may signify agreement in one culture but acknowledgment in another. Individual personality or mental health conditions also influence nonverbal cues, making this statement accurate as it accounts for diverse interpretations.

Choice D reason: Therapeutic touch responses vary by individual and cultural preferences, and some patients may find it intrusive or distressing. Verbal interaction is often more consistent in therapeutic settings, as it allows clearer communication of intent. Touch is not universally more effective, making this statement inaccurate.

A. Behavior that may be viewed as acceptable in one culture yet unacceptable in other cultures B. Mental health is a state of emotional, psychological, and social wellness evidenced by use of positive coping strategies C. Persons who engage in fantasies are mentally ill D. It is easy to determine if a person is mentally healthy or mentally ill by monitoring one’s verbal and nonverbal communication

Correct Answer is B

Explanation

Choice A reason: While behavior acceptability varies across cultures, this statement does not fully define mental health or illness. Cultural norms influence behavior interpretation, but mental health involves emotional and psychological well-being, not just cultural acceptability, making this option incomplete as a definition of mental health or illness.

Choice B reason: Mental health is characterized by emotional, psychological, and social well-being, reflected in adaptive coping strategies like problem-solving or seeking support. This holistic state enables individuals to manage stress and function effectively, making this statement a comprehensive and accurate description of mental health in contrast to mental illness.

Choice C reason: Engaging in fantasies is not inherently indicative of mental illness, as it can be a normal part of creativity or coping. Only when fantasies disrupt functioning or reflect delusions does it suggest illness. This statement is inaccurate, as it overgeneralizes a common behavior as pathological.

Choice D reason: Determining mental health or illness via verbal and nonverbal communication is complex and not always reliable. Cultural, individual, and contextual factors obscure interpretation, and clinical assessment requires comprehensive evaluation beyond communication, making this statement inaccurate as a definitive method for assessing mental health status.

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A client diagnosed with chronic kidney disease is completing an exchange during peritoneal dialysis. The nurse observes that the peritoneal fluid is draining slowly and that the client’s abdomen is increasing in girth. What is the nurse’s most appropriate action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which statement about nonverbal communication is accurate?

Correct Answer is C

Explanation

Which of the following is true regarding mental health and mental illness?

Correct Answer is B

Explanation

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The nurse is performing an admission assessment for a client on the behavioral health unit with depression and anxiety. Which goal of therapeutic communication will the nurse prioritize?