A client with chronic renal failure is admited with a heart rate of 122 beats/minute; a respiratory rate of 32 breaths/minute, a blood pressure of 190/110 mm Hg, neck vein distention, and bibasilar crackles. Which nursing diagnosis takes highest priority for this client? Select one answer

Fear

Toileting self-care deficit

Excess ﬂuid volume

Urinary retention

Answer and Explanation

The Correct Answer is A

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.

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Correct Answer is B

Explanation

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.

A. "I can see you are worried.” B. “Don’t worry, you have nothing to feel guilty about.” C. "Everything possible is being done.” D. "Let me check if you can see your loved one.”

Correct Answer is A

Explanation

Choice A reason: “I can see you are worried.” is a therapeutic response by the PN to the family at this time. This response shows empathy, which is the ability to understand and share the feelings of another person. It also acknowledges and validates the family’s emotions, and invites them to express their concerns or fears. Therefore, this choice is correct.

Choice B reason: “Don’t worry, you have nothing to feel guilty about.” is not a therapeutic response by the PN to the family at this time. This response shows false reassurance, which is a communication technique that involves minimizing or dismissing the other person’s feelings or situation. It also implies that the family should feel guilty, and denies them the opportunity to explore their feelings or thoughts. Therefore, this choice is incorrect.

Choice C reason: “Everything possible is being done.” is not a therapeutic response by the PN to the family at this time. This response shows cliché, which is a communication technique that involves using overused or trite expressions that lack meaning or sincerity. It also avoids addressing the family’s emotions or needs, and may sound vague or insincere. Therefore, this choice is incorrect.

Choice D reason: “Let me check if you can see your loved one.” is not a therapeutic response by the PN to the family at this time. This response shows changing the subject, which is a communication technique that involves shifting the focus away from the other person’s feelings or situation. It also ignores or postpones the family’s emotional needs, and may make them feel unimportant or dismissed. Therefore, this choice is incorrect.

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A client with chronic renal failure is admited with a heart rate of 122 beats/minute; a respiratory rate of 32 breaths/minute, a blood pressure of 190/110 mm Hg, neck vein distention, and bibasilar crackles. Which nursing diagnosis takes highest priority for this client? Select one answer

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Naxlex Comprehensive Predictor Exams

A client is admited with the following vital signs: temperature 102oF (38.9oC); heart rate 144 beats/minute and irregular;, and respiratory rate 22 breaths/minute. Which nursing diagnosis takes highest priority when planning this client’s care? Select one answer

Correct Answer is B

Explanation

Family members awaiting the outcome of a suicide atempt are tearful. Which response by the Practical Nurse (PN) is therapeutic to the family at this time? * Select one answer

Correct Answer is A

Explanation

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

Which statements describe a desired patient outcome or expected outcome? (Select all that apply)

A client with carotid stenosis has just discussed an upcoming surgery with the physician. The client tells the Practical Nurse (PN), “I wonder if I should let him cut my neck open?” Which nursing response is best?

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 nurse is changing a client’s dressing. Which observation warrants immediate physician notification?

A Practical Nurse (PN) is observing a nursing assistant talking to a client who is hearing impaired. The PN should not intervene if which of the following were performed by the nursing assistant during communication with the client: (Select all that apply)

The Practical Nurse (PN) uses the “risk for” nursing diagnoses as identified from the: Select all that apply

Subjective data provided by the client included complaints of intermitent chest pain upon exertion. When performing a complete physical examination, the nurse might use an organized approach such as which of the following? (Select all that apply)