Which of the following are approved nursing diagnoses? (Select all that apply)

Insufficient knowledge

Pupils round, reactive to light and accommodation

Pain

Impaired gas exchange

Answer and Explanation

Correct Answer : A,C,D

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.

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Correct Answer is B

Explanation

Choice A reason: "Alcoholism is a disease that aﬀects the whole family.” is not the best response to the client’s husband. This response shows generalization, which is a communication technique that involves using statements that apply to most people in similar situations. It also shows lecturing, which is a communication barrier that involves giving unsolicited advice or information to the other person. It may make the client’s husband feel stereotyped, judged, or patronized, and may discourage further communication. Therefore, this choice is incorrect.

Choice B reason: "You sound frustrated in dealing with your wife’s drinking problem.” is the best response to the client’s husband. This response shows active listening, which is a communication skill that involves hearing, understanding, and responding to the client’s verbal and nonverbal messages. It also shows empathy, which is the ability to understand and share the feelings of another person. It acknowledges and validates the client’s husband’s emotions, and invites him to express his concerns or fears. Therefore, this choice is correct.

Choice C reason: "I think you are a good person to stay here with your wife.” is not the best response to the client’s husband. This response shows praise, which is a communication technique that involves giving positive feedback or recognition to the other person. It also shows assumption, which is a communication barrier that involves making judgments or guesses about what the other person thinks or feels. It may make the client’s husband feel uncomfortable, embarrassed, or pressured, and may not address his underlying feelings or needs. Therefore, this choice is incorrect.

Choice D reason: “Have you discussed this subject at the support group meetings?” is not the best response to the client’s husband. This response shows closed-ended questioning, which is a communication technique that involves asking questions that require a yes or no answer or a specific piece of information. It also shows probing, which is a communication barrier that involves asking too many or inappropriate questions to the other person. It may make the client’s husband feel defensive, invaded, or resentful, and may violate his privacy or confidentiality. Therefore, this choice is incorrect.

A. Select one answer B. counteract shyness in the client C. keep the Practical Nurse’s atention on the conversation D. assess if the client is involved in the conversation

Correct Answer is D

Explanation

Choice A reason: Counteract shyness in the client is not the major eﬀect of maintaining eye contact for 2 to 6 seconds during communication. Eye contact is a nonverbal cue that involves looking at the other person’s eyes or face while communicating. It can have diﬀerent meanings and eﬀects depending on the culture, context, and relationship of the communicators. Maintaining eye contact for 2 to 6 seconds can help to establish rapport, show interest, or convey sincerity, but it may not necessarily counteract shyness in the client. In fact, some clients may feel uncomfortable, intimidated, or threatened by too much eye contact, especially if they are shy, anxious, or from a diﬀerent cultural background. Therefore, this choice is incorrect.

Choice B reason: Keep the Practical Nurse’s atention on the conversation is not the major eﬀect of maintaining eye contact for 2 to 6 seconds during communication. Eye contact is a nonverbal cue that involves looking at the other person’s eyes or face while communicating. It can have diﬀerent meanings and eﬀects depending on the culture, context, and relationship of the communicators. Maintaining eye contact for 2 to 6 seconds can help to keep the

Practical Nurse’s atention on the conversation, but it is not the main purpose or outcome of doing so. The main purpose or outcome of maintaining eye contact is to communicate with the other person eﬀectively and respectfully, not to focus on oneself or one’s own behavior. Therefore, this choice is incorrect.

Choice C reason: Assess if the client is involved in the conversation is not the major eﬀect of maintaining eye contact for 2 to 6 seconds during communication. Eye contact is a nonverbal cue that involves looking at the other person’s eyes or face while communicating. It can have diﬀerent meanings and eﬀects depending on the culture, context, and relationship of the communicators. Maintaining eye contact for 2 to 6 seconds can help to assess if the client is involved in the conversation, but it is not the only or most reliable way of doing so. The Practical Nurse should also pay atention to other verbal and nonverbal cues from the client, such as their tone of voice, facial expressions, body language, or feedback. Therefore, this choice is incorrect.

Choice D reason: Indicate continuous focused atention is the major eﬀect of maintaining eye contact for 2 to 6 seconds during communication. Eye contact is a nonverbal cue that involves looking at the other person’s eyes or face while communicating. It can have diﬀerent meanings and eﬀects depending on the culture, context, and relationship of the communicators. Maintaining eye contact for 2 to 6 seconds can indicate continuous focused atention, which means that the Practical Nurse is listening actively, understanding empathetically, and responding appropriately to the client’s message. It can also show respect, interest, or sincerity to the client, and enhance rapport and trust between them. Therefore, this choice is correct.

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Which of the following are approved nursing diagnoses? (Select all that apply)

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Naxlex Comprehensive Predictor Exams

The husband of a client who has a Sengstaken-Blakemore tube states to the nurse, “I thought having this tube down her nose the first time would convince my wife to quit drinking.” The nurse should make which response to the client’s husband? Select one answer

Correct Answer is B

Explanation

The Practical Nurse (PN) explains that the major eﬀect of maintaining eye contact for 2 to 6 seconds during communication is to:

Correct Answer is D

Explanation

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