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 D

No explanation

A. Select one answer B. counteract shyness in the client C. keep the Practical Nurse’s atention on the conversation D. assess if the client is involved in the conversation

Correct Answer is D

Explanation

Choice A reason: Counteract shyness in the client is not the major eﬀect of maintaining eye contact for 2 to 6 seconds during communication. Eye contact is a nonverbal cue that involves looking at the other person’s eyes or face while communicating. It can have diﬀerent meanings and eﬀects depending on the culture, context, and relationship of the communicators. Maintaining eye contact for 2 to 6 seconds can help to establish rapport, show interest, or convey sincerity, but it may not necessarily counteract shyness in the client. In fact, some clients may feel uncomfortable, intimidated, or threatened by too much eye contact, especially if they are shy, anxious, or from a diﬀerent cultural background. Therefore, this choice is incorrect.

Choice B reason: Keep the Practical Nurse’s atention on the conversation is not the major eﬀect of maintaining eye contact for 2 to 6 seconds during communication. Eye contact is a nonverbal cue that involves looking at the other person’s eyes or face while communicating. It can have diﬀerent meanings and eﬀects depending on the culture, context, and relationship of the communicators. Maintaining eye contact for 2 to 6 seconds can help to keep the

Practical Nurse’s atention on the conversation, but it is not the main purpose or outcome of doing so. The main purpose or outcome of maintaining eye contact is to communicate with the other person eﬀectively and respectfully, not to focus on oneself or one’s own behavior. Therefore, this choice is incorrect.

Choice C reason: Assess if the client is involved in the conversation is not the major eﬀect of maintaining eye contact for 2 to 6 seconds during communication. Eye contact is a nonverbal cue that involves looking at the other person’s eyes or face while communicating. It can have diﬀerent meanings and eﬀects depending on the culture, context, and relationship of the communicators. Maintaining eye contact for 2 to 6 seconds can help to assess if the client is involved in the conversation, but it is not the only or most reliable way of doing so. The Practical Nurse should also pay atention to other verbal and nonverbal cues from the client, such as their tone of voice, facial expressions, body language, or feedback. Therefore, this choice is incorrect.

Choice D reason: Indicate continuous focused atention is the major eﬀect of maintaining eye contact for 2 to 6 seconds during communication. Eye contact is a nonverbal cue that involves looking at the other person’s eyes or face while communicating. It can have diﬀerent meanings and eﬀects depending on the culture, context, and relationship of the communicators. Maintaining eye contact for 2 to 6 seconds can indicate continuous focused atention, which means that the Practical Nurse is listening actively, understanding empathetically, and responding appropriately to the client’s message. It can also show respect, interest, or sincerity to the client, and enhance rapport and trust between them. Therefore, this choice is correct.

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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 Practical Nurse (PN) is planning on leaving the room of a patient with a tracheotomy. The PN ensures that the client has which of the following means of communication before leaving the room?

Correct Answer is D

The Practical Nurse (PN) explains that the major eﬀect of maintaining eye contact for 2 to 6 seconds during communication is to:

Correct Answer is D

Explanation

In what step of the nursing process do the client and the nurse develop the goals? (Select all that apply)

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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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