Subjective data provided by the client included complaints of intermitent chest pain upon exertion. When performing a complete physical examination, the nurse might use an organized approach such as which of the following? (Select all that apply)

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.

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.