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:
Closed inquiry
Open-ended question
Minimal encouraging
Restating
The Correct Answer is B
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["D"]
Explanation
Choice A reason: Needs medical intervention is not the major difference between the two diagnoses. Both diagnoses may require medical intervention, depending on the severity and cause of the vomiting and the nutritional deficiency. Medical intervention is not a criterion for distinguishing between different types of nursing diagnoses.
Therefore, this choice is incorrect.
Choice B reason: Needs no defined nursing interventions is not the major difference between the two diagnoses. Both diagnoses need defined nursing interventions, such as monitoring, teaching, counseling, or providing fluids and electrolytes. Nursing interventions are essential for addressing any nursing diagnosis, whether actual or potential.
Therefore, this choice is incorrect.
Choice C reason: Will not need to be evaluated is not the major difference between the two diagnoses. Both diagnoses need to be evaluated, which involves measuring the outcomes and determining whether the interventions were effective in resolving or preventing the problem. Evaluation is a vital step of the nursing process for any nursing diagnosis, whether actual or potential. Therefore, this choice is incorrect.
Choice D reason: Reflects a problem that does not yet exist is the major difference between the two diagnoses. Diagnosis #1 is an actual nursing diagnosis, which reflects a problem that exists at the present time and has signs and symptoms that can be observed or measured. Diagnosis #2 is a risk for nursing diagnosis, which reflects a problem that does not exist at the present time but may develop in the future if preventive measures are not taken.
Therefore, this choice is correct.
Correct Answer is ["A","D"]
Explanation
Choice A reason: Client O2 saturation will be maintained at 95% the entire day is an example of an expected outcome that adheres to accepted criteria. An expected outcome is a measurable and realistic goal that the client should achieve as a result of the nursing interventions. Accepted criteria for writing expected outcomes include being client- centered, specific, observable, measurable, time-limited, and realistic. This outcome meets all these criteria, as it focuses on the client’s condition, states a specific value and time frame, and can be observed and measured.
Therefore, this choice is correct.
Choice B reason: Client will observe safety guidelines while smoking is not an example of an expected outcome that adheres to accepted criteria. This outcome is not specific, observable, or measurable, as it does not state what the safety guidelines are, how they will be observed, or how they will be evaluated. It is also not realistic, as smoking is a harmful behavior that should be discouraged or eliminated, not made safer. Therefore, this choice is incorrect.
Choice C reason: PN will assess vital signs every day is not an example of an expected outcome that adheres to accepted criteria. This outcome is not client-centered, as it focuses on the nurse’s action, not the client’s condition or response. It is also not an outcome, but rather an intervention or activity that the nurse will perform to monitor the client’s status. Therefore, this choice is incorrect.
Choice D reason: Client will take part in one activity daily for the next 90 days is an example of an expected outcome that adheres to accepted criteria. This outcome is client-centered, specific, observable, measurable, time-limited, and realistic, as it focuses on the client’s participation, states a specific frequency and duration, and can be observed and measured. It also implies a positive change in the client’s behavior or lifestyle that may improve their health or well- being. Therefore, this choice is correct.
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