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: This is incorrect because it shows that the PN is not using a technique that encourages the client to express feelings and thoughts. A closed inquiry is a question that can be answered with a yes or no, or a short factual response.

Choice B reason: This is correct because it shows that the PN is using a technique that encourages the client to express feelings and thoughts. An open-ended question is a question that requires more than a yes or no, or a short factual response and invites the client to elaborate.

Choice C reason: This is incorrect because it shows that the PN is not using a technique that involves asking a question. Minimal encouraging is a verbal or nonverbal response that shows interest and attention and prompts the client to continue talking.

Choice D reason: This is incorrect because it shows that the PN is not using a technique that involves asking a question. A restating is a verbal response that repeats the main idea or keywords of the client’s message and confirms understanding.

Choice A reason: Fear is a nursing diagnosis that indicates a problem with the client’s emotional response to a perceived threat or danger. It can be caused by factors such as uncertainty, lack of control, or loss of function. It can result in symptoms such as anxiety, restlessness, or palpitations. The client may experience fear related to their chronic renal failure and its complications, but it is not the highest priority nursing diagnosis, as it is not directly affecting their physical health or safety. Therefore, this choice is incorrect.

Choice B reason: Toileting self-care deficit is a nursing diagnosis that indicates a problem with the client’s ability to perform or complete activities related to urination or defecation. It can be caused by factors such as physical impairment, cognitive impairment, or environmental barriers. It can result in symptoms such as incontinence, constipation, or skin breakdown. The client may have a toileting self-care deficit related to their chronic renal failure and its effects on their urinary function, but it is not the highest priority nursing diagnosis, as it is not immediately life-threatening. Therefore, this choice is incorrect.

Choice C reason: Excess fluid volume is a nursing diagnosis that indicates a problem with the retention of water and sodium in the body. It can be caused by factors such as renal failure, heart failure, or liver cirrhosis. It can result in symptoms such as edema, hypertension, tachycardia, dyspnea, or crackles. The client’s vital signs and physical findings suggest that they have excess fluid volume, which is the highest priority nursing diagnosis, as it can lead to pulmonary edema, cardiac arrhythmias, or stroke if not treated promptly. Therefore, this choice is correct.

Choice D reason: Urinary retention is a nursing diagnosis that indicates a problem with the inability to empty the bladder completely or at all. It can be caused by factors such as obstruction, infection, or medication. It can result in symptoms such as difficulty or pain in urinating, frequent or urgent urination, or abdominal distension. The client may have urinary retention related to their chronic renal failure and its effects on their bladder function, but it is not the highest priority nursing diagnosis, as it is not directly causing their fluid overload or cardiovascular compromise. Therefore, this choice is incorrect.