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)

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.

Choice A reason: Providing open-ended questions and silence is a communication technique that can encourage the client to eat dinner. Open-ended questions can invite the client to share their thoughts and feelings about food and eating, and can help the nurse to explore the client’s perception of reality and identify any distorted thinking. Silence can give the client time to process and respond, and can show respect and acceptance. Therefore, this choice is correct.

Choice B reason: Focusing on self-disclosure of own food preferences is not a communication technique that can encourage the client to eat dinner. Self-disclosure can be appropriate in some situations, but it should be used sparingly and only when it benefits the client. Focusing on the nurse’s own food preferences can be irrelevant, distracting, or imposing, and it can shift the atention away from the client’s needs and concerns. Therefore, this choice is incorrect.

Choice C reason: Atempting to show empathy by suggesting reasons why the client may not want to eat is not a communication technique that can encourage the client to eat dinner. Empathy is a valuable skill, but it should be based on understanding and reflecting the client’s feelings, not on assuming or guessing them. Suggesting reasons why the client may not want to eat can be inaccurate, patronizing, or discouraging, and it can reinforce the client’s resistance or mistrust. Therefore, this choice is incorrect.

Choice D reason: Telling the client of the importance of eating is not a communication technique that can encourage the client to eat dinner. Telling or lecturing the client can be perceived as authoritative, judgmental, or condescending, and it can increase the client’s defensiveness or anxiety. It can also ignore the client’s perspective or experience, and fail to address the underlying causes of their disordered thinking. Therefore, this choice is incorrect.