the nurse is obtaining a history of an 80 year old client which statement made by the client might indicate a possible fluid and electrolyte imbalance
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Nursing Elites

NCLEX-PN

Nclex 2024 Questions

1. During the history assessment of an 80-year-old client, which statement made by the client might indicate a possible fluid and electrolyte imbalance?

Correct answer: B

Rationale: The correct answer is "I often use a laxative for constipation." Frequent use of laxatives can lead to diarrhea and electrolyte loss, indicating a possible fluid and electrolyte imbalance. Statements A, C, and D are not directly related to fluid and electrolyte imbalance. Statement A about dry skin may suggest dehydration, but it is less specific to electrolyte imbalance than the frequent use of laxatives. Statement C about drinking a lot of iced tea could potentially relate to fluid intake, but it doesn't directly indicate an imbalance. Statement D about dribbling urine is more indicative of a potential urinary issue rather than a fluid and electrolyte imbalance.

2. After the client discusses her relationship with her father, the nurse says, "Tell me whether I am understanding your relationship with your father. You feel dominated and controlled by him?"? This is an example of:

Correct answer: B

Rationale: Seeking consensual validation is the correct answer. Consensual validation is a technique used to check one's understanding of what the client has said. It involves confirming with the client whether the nurse's interpretation aligns with the client's feelings or thoughts. This process helps build rapport, trust, and a shared understanding between the nurse and the client. Verbalizing the implied (choice A) refers to expressing the underlying or implicit meaning of a client's statement. Encouraging evaluation (choice C) involves prompting the client to assess or judge a situation. Suggesting collaboration (choice D) entails proposing working together with the client on a shared goal, which is not the primary focus in the scenario provided.

3. The nurse notes the patient care assistant looking through the personal items of the client with cancer. Which action should be taken by the registered nurse?

Correct answer: B

Rationale: The appropriate action for the registered nurse in this scenario is to report the behavior to the charge nurse. This allows for proper investigation and intervention. Inappropriate actions include notifying the police directly without following the chain of command (Choice A), monitoring without immediate action (Choice C), and confronting the assistant without involving a superior (Choice D). By reporting to the charge nurse, the situation is escalated appropriately within the healthcare setting, ensuring the well-being and safety of the client.

4. All of the following are common reasons that nurses are reluctant to delegate except:

Correct answer: C

Rationale: If a delegator has confidence in their subordinates and believes a task will be performed correctly, they are more likely to delegate. Reasons nurses may be reluctant to delegate include their own lack of self-confidence, the desire to maintain authority, and getting trapped in the 'I can do it better myself' mindset. Therefore, 'confidence in subordinate' is the exception as it actually encourages delegation. The other choices are common barriers to delegation in healthcare settings.

5. The women's health charge nurse is making assignments for the next shift. The unit is short one staff member and will receive a nurse from the medical-surgical unit. Which group of clients should she assign to the medical-surgical nurse?

Correct answer: A

Rationale: The correct answer includes clients who have undergone surgical procedures typically managed on a medical-surgical unit. Choice A consists of clients who have had elective surgical procedures such as hysterectomy, bladder suspension with A&P repair, and breast reduction, which are commonly treated in a medical-surgical setting. Choices B, C, and D involve clients with various complications related to childbirth, fetal demise, pneumonia, gestational lymphoma, HELLP syndrome, and bed rest, which are more complex cases requiring specialized care beyond medical-surgical nursing.

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