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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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. The new mother asks why her baby has lost weight since he was born. The best explanation of the weight loss is:

Correct answer: D

Rationale: After birth, newborns can lose weight due to meconium stool, loss of extracellular fluid, and the initiation of breastfeeding. This weight loss is a normal and expected physiological process, and infants can lose up to 10% of their birth weight during this period. There is no indication of dehydration (polyuria), hypoglycemia (lack of glucose), or allergy to the formula as reasons for weight loss in newborns. Therefore, answers A, B, and C are incorrect. Answer D provides the most accurate explanation for the observed weight loss in the newborn.

3. While walking in the hallway of an acute care unit of the hospital, the nurse overhears the change of shift report. What should the nurse do?

Correct answer: A

Rationale: To protect the confidentiality of the information being reported, the nurse should make the charge nurse on the unit aware of the situation. This allows the charge nurse to take necessary steps to maintain confidentiality and ensure that the information is communicated in an appropriate and private manner. Disclosing the situation to the charge nurse is essential to address any breaches in confidentiality and uphold professional standards of privacy and ethics. Disregarding the information, returning to their own unit without disclosure, or ignoring the situation altogether would not address the breach of confidentiality and could lead to further issues regarding patient privacy and trust.

4. The client is being assessed for possible pernicious anemia. Which finding would support this diagnosis?

Correct answer: C

Rationale: The correct answer is a red, beefy tongue, which is characteristic of pernicious anemia due to the atrophy of the papillae on the tongue. This finding is known as glossitis. A red, beefy tongue is a classic sign of pernicious anemia. Choice A, weight loss of 10 pounds in 2 weeks, is non-specific and not a typical finding in pernicious anemia. Choice B, complaints of numbness and tingling in the extremities, are more indicative of peripheral neuropathy, a common symptom of vitamin B12 deficiency, which can be seen in pernicious anemia. Choice D, a hemoglobin level of 12.0 g/dL, falls within the normal range and does not specifically point towards pernicious anemia, which is characterized by low hemoglobin levels due to impaired absorption of vitamin B12.

5. What should the charge nurse do after overhearing the patient care assistant speaking harshly to the client with dementia?

Correct answer: B

Rationale: The best action for the charge nurse to take is to explore the interaction with the patient care assistant. This step allows for clarification of the situation and direct addressing of the issue. Changing the patient care assistant's assignment (choice A) might be necessary, but understanding the situation should come first. Discussing the matter with the client's family (choice C) as an initial step could escalate the situation. Initiating a group session with the patient care assistant (choice D) could be considered later as a preventive measure to avoid similar incidents in the future.

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