During the planning step of the nursing process, the nurse performs which activity? Select one answer

Collects data

Records data

Prioritizes care

Carries out interventions

Answer and Explanation

The Correct Answer is C

Choice A reason: Collects data is not an activity that the nurse performs during the planning step of the nursing process. Collecting data is an activity that the nurse performs during the assessment step of the nursing process, which involves gathering and analyzing information about the client’s health status, history, and environment.

Therefore, this choice is incorrect.

Choice B reason: Records data is not an activity that the nurse performs during the planning step of the nursing process. Recording data is an activity that the nurse performs during the documentation step of the nursing process, which involves writing or entering the data and findings in the client’s record or chart. Therefore, this choice is incorrect.

Choice C reason: Prioritizes care is an activity that the nurse performs during the planning step of the nursing process. Prioritizing care is an activity that involves ranking the client’s problems, needs, or risks according to their urgency, importance, or potential impact. It helps the nurse to allocate time and resources efficiently, and to address the most critical or significant issues first. Therefore, this choice is correct.

Choice D reason: Carries out interventions is not an activity that the nurse performs during the planning step of the nursing process. Carrying out interventions is an activity that the nurse performs during the implementation step of the nursing process, which involves executing the plan of care and performing the interventions and activities that were planned. Therefore, this choice is incorrect.

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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.

A. Closed inquiry B. Open-ended question C. Minimal encouraging D. Restating

Correct Answer is B

Explanation

Choice A reason: This is incorrect because it shows that the PN is not using a technique that encourages the client to express feelings and thoughts. A closed inquiry is a question that can be answered with a yes or no, or a short factual response.

Choice B reason: This is correct because it shows that the PN is using a technique that encourages the client to express feelings and thoughts. An open-ended question is a question that requires more than a yes or no, or a short factual response and invites the client to elaborate.

Choice C reason: This is incorrect because it shows that the PN is not using a technique that involves asking a question. Minimal encouraging is a verbal or nonverbal response that shows interest and attention and prompts the client to continue talking.

Choice D reason: This is incorrect because it shows that the PN is not using a technique that involves asking a question. A restating is a verbal response that repeats the main idea or keywords of the client’s message and confirms understanding.

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During the planning step of the nursing process, the nurse performs which activity? Select one answer

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

The young client says, “I’m really stressed out about this pregnancy.” When the Practical Nurse (PN) responds, “What about this pregnancy worries you?”, he or she is using the technique of:

Correct Answer is B

Explanation

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

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

Which statements describe a desired patient outcome or expected outcome? (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

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?

The Practical Nurse (PN) uses the “risk for” nursing diagnoses as identified from the: Select all that apply

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

During the planning step of the nursing process, the nurse performs which activity? Select one answer