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:
Select one answer
Symptoms
Urinary retention
Signs of fluid overload
The Correct Answer is A
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Restating is a therapeutic communication technique that involves repeating or paraphrasing what the client has said to show understanding and clarify meaning. It is not an appropriate intervention to provide comfort during a painful procedure, especially when the client does not speak English. Therefore, this choice is incorrect.
Choice B reason: Listening is a therapeutic communication technique that involves paying atention and showing interest in what the client has to say. It is an important skill for building rapport and trust, but it is not an effective intervention to provide comfort during a painful procedure, especially when the client does not speak English.
Therefore, this choice is incorrect.
Choice C reason: Silence is a therapeutic communication technique that involves allowing pauses or gaps in the conversation to give the client time to think, reflect, or express emotions. It can be useful in some situations, but it is not a sufficient intervention to provide comfort during a painful procedure, especially when the client does not speak English. Therefore, this choice is incorrect.
Choice D reason: Touch is a nonverbal communication technique that involves using physical contact to convey empathy, support, or reassurance. It can be a powerful intervention to provide comfort during a painful procedure, as long as it is done with respect, consent, and cultural sensitivity. It can also transcend language barriers and communicate caring and compassion. Therefore, this choice is correct.
Correct Answer is ["A","C","D"]
Explanation
Choice A reason: This is correct because it is an approved nursing diagnosis that describes a lack of cognitive information related to a specific topic.
Choice B reason: This is incorrect because it is not an approved nursing diagnosis, but rather a data or assessment finding that describes the condition of the client’s pupils.
Choice C reason: This is correct because it is an approved nursing diagnosis that describes an unpleasant sensory and emotional experience associated with actual or potential tissue damage.
Choice D reason: This is correct because it is an approved nursing diagnosis that describes a decrease in oxygenation and/or elimination of carbon dioxide at the alveolar-capillary membrane.
Choice E reason: This is incorrect because it is not an approved nursing diagnosis, but rather a medical diagnosis that describes a malignant neoplasm of any body part.
Choice F reason: This is incorrect because it is not an approved nursing diagnosis, but rather a medical diagnosis that describes a dysfunction of the kidneys.
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