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

Answer and Explanation

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.

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Correct Answer is ["A"]

Explanation

Choice A reason: This is correct because it shows that the nurse is engaged and focused on the patient. Leaning slightly forward indicates that the nurse is listening and caring.

Choice B reason: This is correct because it shows that the nurse is open and receptive to the patient’s feelings and concerns. An open posture means that the nurse does not cross arms or legs, which can be seen as defensive or closed.

Choice C reason: This is incorrect because it shows that the nurse is distant and distracted from the patient. Standing at the doorway implies that the nurse is ready to leave or has other priorities. Reading the chart while smiling may seem insincere or superficial.

Choice D reason: This is correct because it shows that the nurse is respectful and atentive to the patient. Sitting at the bedside and facing the patient indicates that the nurse is giving eye contact and acknowledging the patient’s

presence.

A. the message as: B. The Practical Nurse recognizes the communication technique of receiving information and examining responses to C. the message as: D. Listening

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.

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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:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of the following types of posture is best for the nurse to use when communicating with the patient? (Select all that apply)

Correct Answer is ["A"]

Explanation

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

Correct Answer is A

Explanation

The client does not speak English; therefore, the Practical Nurse (PN) cannot use words to provide comfort during a painful procedure. The PN selects another intervention to provide comfort, which is: * Select one answer

When a female client preparing for surgery suddenly bursts into tears, the nurse should take which of the following actions? · Select one answer

A client is admited with the following vital signs: temperature 102oF (38.9oC); heart rate 144 beats/minute and irregular;, and respiratory rate 22 breaths/minute. Which nursing diagnosis takes highest priority when planning this client’s care? Select one answer

In what step of the nursing process do the client and the nurse develop the goals? (Select all that apply)

The husband of a client who has a Sengstaken-Blakemore tube states to the nurse, “I thought having this tube down her nose the first time would convince my wife to quit drinking.” The nurse should make which response to the client’s husband? Select one answer

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

Which statement best defines the nursing process? Select one answer