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

Choice A reason: This is correct because it shows that the nurse is respectful and sensitive to the client’s language and cultural needs. Speaking slowly and providing examples can help the client comprehend and retain the information.

Choice B reason: This is incorrect because it shows that the nurse is overwhelming and insensitive to the client’s language and cultural needs. Giving too much information or using complex terms can confuse and frustrate the client.

Choice C reason: This is incorrect because it shows that the nurse is assuming and delegating the responsibility of communication to someone else. Getting an interpreter or a family member may not be necessary or appropriate if the client speaks English. The nurse should communicate directly with the client as much as possible.

Choice D reason: This is incorrect because it shows that the nurse is rude and disrespectful to the client’s language and cultural needs. Speaking quickly and avoiding eye contact can make the client feel ignored or intimidated. The nurse should maintain eye contact and speak at a normal pace.

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.