What should the nurse do with linens that have been soiled by a client with hepatitis?

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.

Choice A reason: Gives the same message to the patient verbally and nonverbally is an example of using assertive communication, not a sign of needing further teaching on it. Assertive communication is a communication style that involves expressing one’s thoughts, feelings, and needs in a clear, respectful, and confident manner. It also involves using congruent verbal and nonverbal cues, such as eye contact, tone of voice, and body language, to reinforce the message and avoid confusion or misunderstanding. Therefore, this choice is incorrect.

Choice B reason: Speaks firmly and positively is an example of using assertive communication, not a sign of needing further teaching on it. Assertive communication is a communication style that involves expressing one’s thoughts, feelings, and needs in a clear, respectful, and confident manner. It also involves using firm and positive language, such as “I” statements, active verbs, and constructive feedback, to convey the message and avoid aggression or passivity. Therefore, this choice is incorrect.

Choice C reason: Is unapologetic is an example of using assertive communication, not a sign of needing further teaching on it. Assertive communication is a communication style that involves expressing one’s thoughts, feelings,

and needs in a clear, respectful, and confident manner. It also involves being unapologetic for one’s opinions, beliefs, or values, as long as they do not harm or disrespect others. It does not mean being rude or arrogant, but rather being honest and authentic. Therefore, this choice is incorrect.

Choice D reason: Agrees to do whatever the patient requests is a sign of needing further teaching on using assertive communication, not an example of it. Agreeing to do whatever the patient requests is a communication style that involves suppressing one’s thoughts, feelings, and needs in order to please or avoid conflict with others. It is a form of passive communication, which can lead to resentment, frustration, or loss of self-esteem. It can also compromise the quality of care or the safety of the patient or the nurse. Therefore, this choice is correct.