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

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.

Choice A reason: Symptoms are subjective data that are reported by the client, such as pain, nausea, or fatigue. They are not observable or measurable by the nurse, and they may vary depending on the client’s perception or expression. The data that the PN discovered are not symptoms, but objective data that are observed or measured by the nurse, such as skin condition, oral mucus membranes, and temperature. Therefore, this choice is incorrect.

Choice B reason: Urinary retention is a condition in which the client is unable to empty the bladder completely or at all. It can cause symptoms such as difficulty or pain in urinating, frequent or urgent urination, or abdominal distension. It can also lead to complications such as infection, kidney damage, or bladder rupture. The data that the PN discovered are not related to urinary retention, but to dehydration or fever. Therefore, this choice is incorrect.

Choice C reason: Signs of fluid overload are objective data that indicate excess fluid in the body, such as edema, weight gain, crackles in the lungs, or elevated blood pressure. They can result from conditions such as heart failure,

kidney failure, or liver cirrhosis. The data that the PN discovered are not signs of fluid overload, but signs of fluid deficit or heat stroke. Therefore, this choice is incorrect.

Choice D reason: Data clustering is a process of grouping related data together to form a meaningful patern that can support a nursing diagnosis. It can help the nurse to identify the client’s problems, needs, or risks, and to prioritize and plan interventions accordingly. The data that the PN discovered are an example of data clustering, as they represent a patern of signs that indicate a possible problem such as dehydration or fever. Therefore, this choice is correct.