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","B","D"]

Explanation

Choice A reason: The nursing assistant is speaking in a normal tone is an action that the PN should not intervene in during communication with the client who is hearing impaired. Speaking in a normal tone can help the client to hear the natural variations and inﬂections of the voice, and to avoid distortion or confusion. Speaking in a high-pitched or

low-pitched tone can make the voice harder to hear or understand, especially if the client has a hearing loss in a specific frequency range. Therefore, this choice is correct.

Choice B reason: The nursing assistant is facing the client while speaking is an action that the PN should not intervene in during communication with the client who is hearing impaired. Facing the client while speaking can help the client to see the facial expressions and lip movements of the speaker, and to enhance visual cues and feedback. Facing away from the client while speaking can make the voice muﬄed or unclear, and can interfere with eye contact or rapport. Therefore, this choice is correct.

Choice C reason: The nursing assistant is speaking directly into the impaired ear is an action that the PN should intervene in during communication with the client who is hearing impaired. Speaking directly into the impaired ear can create an uncomfortable or unnatural position for the client and the speaker, and interfere with eye contact or facial expressions. Speaking directly into the impaired ear can also create a loud or distorted sound that may be unpleasant or painful for the client. Speaking face-to-face, and slightly toward the unaﬀected ear, can improve communication with a client who is hearing impaired. Therefore, this choice is incorrect.

Choice D reason: The nursing assistant is speaking clearly to the client is an action that the PN should not intervene in during communication with the client who is hearing impaired. Speaking clearly to the client can help the client to hear and understand the words and sentences of the speaker, and to avoid miscommunication or misunderstanding. Speaking unclearly to the client can make the voice garbled or incomprehensible, and can cause frustration or confusion. Therefore, this choice is correct.

A. A wellness nursing diagnosis B. A syndrome nursing diagnosis C. A ‘risk for’ nursing diagnosis D. An actual nursing diagnosis

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.

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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

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)

Correct Answer is ["A","B","D"]

Explanation

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

Correct Answer is C

Explanation

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