A patient roughly asks the nurse to bring him some ice cream. An assertive response by the nurse is:

“You are hungry and want a snack. I can do that in 10 minutes when I finish my rounds.”

“Maybe I can get one of the aides to bring you something in a while.”

“Call the nursing station and ask them to have the kitchen bring whatever you want.”

“I understand that you would like some ice cream, but I need you to be more respectful when you ask me for something.”

Answer and Explanation

The Correct Answer is D

D) “I understand that you would like some ice cream, but I need you to be more respectful when you ask me for something.” This is an assertive response because it acknowledges the patient’s request, expresses the nurse’s feelings, and sets a clear boundary for acceptable behavior. Assertiveness is the ability to communicate one’s needs, opinions, and feelings in a respectful and confident manner.

“You are hungry and want a snack. I can do that in 10 minutes when I finish my rounds.” is incorrect. This is a passive response because it does not address the patient’s rudeness or assert the nurse’s rights. Passive communication is the tendency to avoid conﬂict, suppress one’s feelings, and comply with others’ demands.

“Maybe I can get one of the aides to bring you something in a while.” is incorrect. This is an evasive response because it does not commit to fulfilling the patient’s request or confronting the patient’s attitude. Evasive communication is the tendency to avoid responsibility, give vague answers, and shift blame to others.

“Call the nursing station and ask them to have the kitchen bring whatever you want.” is incorrect. This is an aggressive response because it rejects the patient’s request, shows irritation, and implies that the nurse does not care about the patient’s needs. Aggressive communication is the tendency to dominate, criticize, and blame others.

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Correct Answer is A

Explanation

Listening. Listening is the process of receiving information from a speaker and examining one’s responses to the message. It involves paying atention, interpreting, and evaluating what is being said. Listening is an essential skill for eﬀective communication in nursing.

Reﬂection is incorrect. Reﬂection is the process of thinking back on one’s actions and experiences and analyzing what went well and what can be improved. Reﬂection helps nurses to learn from their practice and enhance their professional development.

Restating is incorrect. Restating is the process of repeating what the speaker has said in one’s own words to confirm understanding and show interest. Restating is a technique that can facilitate listening, but it is not the same as listening itself.

Clarification is incorrect. Clarification is the process of asking questions or requesting more information to clear up any confusion or ambiguity in the message. Clarification can help to avoid misunderstandings and ensure accuracy, but it is not the same as listening itself.

A. Fear B. Toileting self-care deficit C. Excess ﬂuid volume D. Urinary retention

Correct Answer is A

Explanation

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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A patient roughly asks the nurse to bring him some ice cream. An assertive response by the nurse is:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The Practical Nurse recognizes the communication technique of receiving information and examining responses to

Correct Answer is A

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

Correct Answer is A

Explanation

When writing expected outcomes, the Practical Nurse (PN) should adhere to accepted criteria, such as which of the following? (Select all that apply)

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 nurse is preparing to explain an upcoming procedure to an English-speaking Latino client. The nurse determines that the best way to verbally communicate with this client is to:

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)

A client is to be discharged from an acute care facility after treatment for right leg thrombophlebitis. The nurse notes that the client’s leg is pain free, without redness or edema. The nurse’s actions reﬂect which phase of the nursing process? Select one answer

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:

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?

Which statement best defines the nursing process? Select one answer