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)?

Choice A reason: Ineffective thermoregulation is a nursing diagnosis that indicates a problem with the body’s ability to maintain a normal temperature range. It can be caused by factors such as infection, inflammation, or environmental exposure. It can result in symptoms such as fever, chills, sweating, or shivering. The client’s temperature of 102oF (38.9oC) suggests that they have ineffective thermoregulation, but it is not the highest priority nursing diagnosis, as it is not immediately life-threatening. Therefore, this choice is incorrect.

Choice B reason: Decreased cardiac output is a nursing diagnosis that indicates a problem with the amount of blood pumped by the heart per minute. It can be caused by factors such as arrhythmias, heart failure, or shock. It can result in symptoms such as hypotension, tachycardia, dyspnea, or oliguria. The client’s heart rate of 144 beats/minute and irregular suggests that they have decreased cardiac output, which is the highest priority nursing diagnosis, as it can lead to organ failure or death if not treated promptly. Therefore, this choice is correct.

Choice C reason: Ineffective breathing patern is a nursing diagnosis that indicates a problem with the rate, rhythm, depth, or quality of respirations. It can be caused by factors such as airway obstruction, lung disease, or anxiety. It can result in symptoms such as dyspnea, cyanosis, or hypoxia. The client’s respiratory rate of 22 breaths/minute is within the normal range and does not indicate an ineffective breathing patern. Therefore, this choice is incorrect.

Choice D reason: Ineffective renal tissue perfusion is a nursing diagnosis that indicates a problem with the blood flow to the kidneys. It can be caused by factors such as renal artery stenosis, dehydration, or sepsis. It can result in symptoms such as oliguria, hematuria, or azotemia. The client’s vital signs do not indicate an ineffective renal tissue perfusion, and there is no evidence of renal impairment or dysfunction. Therefore, this choice is incorrect.

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.