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 The nurse notes that the client has had no visitors, seems withdrawn, avoids eye contact and refuses to take part in conversation.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 C
Explanation
Choice A reason: Be silent as a sign of compassion is not an appropriate action for the nurse to take when a client bursts into tears. Silence can be misinterpreted as indifference, disapproval, or rejection, and it can make the client feel more isolated or uncomfortable. Therefore, this choice is incorrect.
Choice B reason: Continue with the physical preparation of the client is not an appropriate action for the nurse to take when a client bursts into tears. Continuing with the task without acknowledging the client’s emotional state can be perceived as insensitive, uncaring, or disrespectful, and it can increase the client’s anxiety or distress. Therefore, this choice is incorrect.
Choice C reason: Ask the client to share what she is feeling is an appropriate action for the nurse to take when a client bursts into tears. Asking open-ended questions can encourage the client to express her emotions, concerns, or fears, and it can show that the nurse is interested, supportive, and empathetic. It can also help the nurse to identify the source of the client’s distress and provide appropriate interventions or referrals. Therefore, this choice is correct.
Choice D reason: Pull the curtain and leave the area to provide privacy is not an appropriate action for the nurse to take when a client bursts into tears. Leaving the client alone can make her feel abandoned, ignored, or unimportant, and it can prevent the nurse from providing emotional support or assistance. Therefore, this choice is incorrect.
Correct Answer is C
Explanation
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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