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

Choice A reason: “I hear frustration or perhaps anger in your voice. Could you tell me more about how you are feeling right now?” is a therapeutic response, not a non-therapeutic one. This response shows active listening, which is a communication skill that involves hearing, understanding, and responding to the client’s verbal and nonverbal messages. It also shows empathy, which is the ability to understand and share the feelings of another person. It acknowledges and validates the client’s emotions, and invites them to express their concerns or fears. Therefore, this choice is incorrect.

Choice B reason: “It sounds as though you are nervous about going home, but the wound care nurse who will see you also uses excellent technique I am sure your wound will continue to heal.” is a non-therapeutic response, not a therapeutic one. 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 address the client’s emotions or needs, and may sound vague or insincere. Therefore, this choice is correct.

Choice C reason: “Do you have any concerns about what will happen after discharge that you would like to talk about?” is a therapeutic response, not a non-therapeutic one. This response shows open-ended questioning, which is a communication technique that involves asking questions that require more than a yes or no answer. It also shows support, which is a communication technique that involves providing emotional or practical assistance to the client, and helping them cope with their situation or problem. It encourages the client to share their thoughts and feelings, and shows that the nurse is interested, supportive, and empathetic. Therefore, this choice is incorrect.

Choice D reason: “Many people who have been in the hospital for an extended period have mixed feelings about going home. Can you tell me how you are feeling about discharge?” is a therapeutic response, not a non-therapeutic one. This response shows generalization, which is a communication technique that involves using statements that apply to most people in similar situations. It also shows reflection, which is a communication technique that involves restating or paraphrasing what the client has said to show understanding and clarify meaning. It helps the client to feel less alone or isolated, and to explore their own feelings or thoughts. Therefore, this choice is incorrect.

Choice A reason: Client O2 saturation will be maintained at 95% the entire day is an example of an expected outcome that adheres to accepted criteria. An expected outcome is a measurable and realistic goal that the client should achieve as a result of the nursing interventions. Accepted criteria for writing expected outcomes include being client- centered, specific, observable, measurable, time-limited, and realistic. This outcome meets all these criteria, as it focuses on the client’s condition, states a specific value and time frame, and can be observed and measured.

Therefore, this choice is correct.

Choice B reason: Client will observe safety guidelines while smoking is not an example of an expected outcome that adheres to accepted criteria. This outcome is not specific, observable, or measurable, as it does not state what the safety guidelines are, how they will be observed, or how they will be evaluated. It is also not realistic, as smoking is a harmful behavior that should be discouraged or eliminated, not made safer. Therefore, this choice is incorrect.

Choice C reason: PN will assess vital signs every day is not an example of an expected outcome that adheres to accepted criteria. This outcome is not client-centered, as it focuses on the nurse’s action, not the client’s condition or response. It is also not an outcome, but rather an intervention or activity that the nurse will perform to monitor the client’s status. Therefore, this choice is incorrect.

Choice D reason: Client will take part in one activity daily for the next 90 days is an example of an expected outcome that adheres to accepted criteria. This outcome is client-centered, specific, observable, measurable, time-limited, and realistic, as it focuses on the client’s participation, states a specific frequency and duration, and can be observed and measured. It also implies a positive change in the client’s behavior or lifestyle that may improve their health or well- being. Therefore, this choice is correct.