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 C

Explanation

Choice A reason: This is incorrect because it shows that the problem is not suspected, but rather the client has a desire to improve or maintain a level of health. A wellness nursing diagnosis describes a potential or actual health state that can be enhanced.

Choice B reason: This is incorrect because it shows that the problem is not suspected, but rather the client has a cluster of related problems that are associated with a specific situation or event. A syndrome nursing diagnosis describes a patern of responses that are linked by a common cause.

Choice C reason: This is correct because it shows that the problem is suspected, but lacks enough data to support it. A ‘risk for’ nursing diagnosis describes a potential problem that may occur if certain risk factors are present.

Choice D reason: This is incorrect because it shows that the problem is not suspected, but rather the client has signs and symptoms that indicate an actual health issue. An actual nursing diagnosis describes a current problem that has been validated by data.

A. Client’s problem B. Care plan C. Evaluation D. Assessment

Correct Answer is ["D"]

Explanation

Choice A reason: Needs medical intervention is not the major diﬀerence between the two diagnoses. Both diagnoses may require medical intervention, depending on the severity and cause of the vomiting and the nutritional deficiency. Medical intervention is not a criterion for distinguishing between diﬀerent types of nursing diagnoses.

Therefore, this choice is incorrect.

Choice B reason: Needs no defined nursing interventions is not the major diﬀerence between the two diagnoses. Both diagnoses need defined nursing interventions, such as monitoring, teaching, counseling, or providing ﬂuids and electrolytes. Nursing interventions are essential for addressing any nursing diagnosis, whether actual or potential.

Therefore, this choice is incorrect.

Choice C reason: Will not need to be evaluated is not the major diﬀerence between the two diagnoses. Both diagnoses need to be evaluated, which involves measuring the outcomes and determining whether the interventions were eﬀective in resolving or preventing the problem. Evaluation is a vital step of the nursing process for any nursing diagnosis, whether actual or potential. Therefore, this choice is incorrect.

Choice D reason: Reﬂects a problem that does not yet exist is the major diﬀerence between the two diagnoses. Diagnosis #1 is an actual nursing diagnosis, which reﬂects a problem that exists at the present time and has signs and symptoms that can be observed or measured. Diagnosis #2 is a risk for nursing diagnosis, which reﬂects a problem that does not exist at the present time but may develop in the future if preventive measures are not taken.

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

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

Correct Answer is C

Explanation

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

Correct Answer is ["D"]

Explanation

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

The basis for designing and selecting nursing interventions to meet client needs is the:

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