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

Choice A reason: This is correct because it shows that the nurse is engaged and focused on the patient. Leaning slightly forward indicates that the nurse is listening and caring.

Choice B reason: This is correct because it shows that the nurse is open and receptive to the patient’s feelings and concerns. An open posture means that the nurse does not cross arms or legs, which can be seen as defensive or closed.

Choice C reason: This is incorrect because it shows that the nurse is distant and distracted from the patient. Standing at the doorway implies that the nurse is ready to leave or has other priorities. Reading the chart while smiling may seem insincere or superficial.

Choice D reason: This is correct because it shows that the nurse is respectful and atentive to the patient. Sitting at the bedside and facing the patient indicates that the nurse is giving eye contact and acknowledging the patient’s

presence.

Choice A reason: Ineffective thermoregulation is a nursing diagnosis that indicates a problem with the body’s ability to maintain a normal temperature range. It can be caused by factors such as infection, inflammation, or environmental exposure. It can result in symptoms such as fever, chills, sweating, or shivering. The client’s temperature of 102oF (38.9oC) suggests that they have ineffective thermoregulation, but it is not the highest priority nursing diagnosis, as it is not immediately life-threatening. Therefore, this choice is incorrect.

Choice B reason: Decreased cardiac output is a nursing diagnosis that indicates a problem with the amount of blood pumped by the heart per minute. It can be caused by factors such as arrhythmias, heart failure, or shock. It can result in symptoms such as hypotension, tachycardia, dyspnea, or oliguria. The client’s heart rate of 144 beats/minute and irregular suggests that they have decreased cardiac output, which is the highest priority nursing diagnosis, as it can lead to organ failure or death if not treated promptly. Therefore, this choice is correct.

Choice C reason: Ineffective breathing patern is a nursing diagnosis that indicates a problem with the rate, rhythm, depth, or quality of respirations. It can be caused by factors such as airway obstruction, lung disease, or anxiety. It can result in symptoms such as dyspnea, cyanosis, or hypoxia. The client’s respiratory rate of 22 breaths/minute is within the normal range and does not indicate an ineffective breathing patern. Therefore, this choice is incorrect.

Choice D reason: Ineffective renal tissue perfusion is a nursing diagnosis that indicates a problem with the blood flow to the kidneys. It can be caused by factors such as renal artery stenosis, dehydration, or sepsis. It can result in symptoms such as oliguria, hematuria, or azotemia. The client’s vital signs do not indicate an ineffective renal tissue perfusion, and there is no evidence of renal impairment or dysfunction. Therefore, this choice is incorrect.