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

Explanation

Choice A reason: “I am sure they are all beef hot dogs. Would you like me to get a substitution from the kitchen?” is not the best response by the PN. 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 assumption, which is a communication barrier that involves making judgments or guesses about what the other person thinks or feels. It does not respect the client’s dietary preferences, and may sound patronizing or condescending. Therefore, this choice is incorrect.

Choice B reason: “I don’t understand why that should make a diﬀerence.” is not the best response by the PN. This response shows lack of knowledge, which is a communication barrier that involves being unaware or ignorant of the other person’s culture, beliefs, or values. It also shows indiﬀerence, which is a communication barrier that involves showing no interest or concern for the other person’s feelings or situation. It does not respect the client’s dietary preferences, and may sound rude or oﬀensive. Therefore, this choice is incorrect.

Choice C reason: “So you don’t want anything to eat, then?” is not the best response by the PN. 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 sarcasm, which is a communication barrier that involves using irony or mockery to hurt or ridicule the other person. It does not respect the client’s dietary preferences, and may sound hostile or aggressive. Therefore, this choice is incorrect.

Choice D reason: “I respect your dietary preferences. Let me see what else I can oﬀer you.” is the best response by the PN. This response shows respect, which is a value or attitude that involves showing consideration, appreciation, and recognition for the other person as a unique and holistic person. It also shows support, which is a communication technique that involves providing emotional or practical assistance to the other person, and helping them cope with their situation or problem. It respects the client’s dietary preferences, and shows that the PN is caring, helpful, and empathetic. Therefore, this choice is correct.

A. Select one answer B. Symptoms C. Urinary retention D. Signs of ﬂuid overload

Correct Answer is A

Explanation

Choice A reason: This is correct because symptoms are subjective or objective manifestations of a health problem that are perceived or reported by the client.

Choice B reason: This is incorrect because urinary retention is a specific condition that involves the inability to empty the bladder completely, which is not related to the data presented.

Choice C reason: This is incorrect because signs of ﬂuid overload are opposite to the data presented, such as edema, weight gain, crackles in the lungs, and distended neck veins.

Choice D reason: This is incorrect because data clustering is a process of grouping related data together to identify paterns and potential problems, not a type of data itself.

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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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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)?

Correct Answer is D

Explanation

During a physical examination, the Practical Nurse (PN) discovers that the client demonstrates signs of ﬂushed, dry, hot skin; dry oral mucus membranes; and temperature elevation. The PN will treat these data as the basis of a nursing diagnosis plan, as they represent:

Correct Answer is A

Explanation

When a problem is suspected, but lacks enough data to support it, the nursing diagnosis is:

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