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

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?

A. “My skin is always so dry.”
B. “I often use a laxative for constipation.”
C. “I have always liked to drink a lot of iced tea.”
D. “I sometimes have a problem with dribbling urine.”

Correct answer: “I often use a laxative for constipation.”

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. A 32-year-old female frequently comes to her primary care provider with vague complaints of headache, abdominal pain, and trouble sleeping. In the past, the physician has dutifully prescribed medication, but little else. Which of the following comments by the nurse to the physician is appropriate?

A. “Often women who are victims of domestic violence suffer vague symptoms such as abdominal pain.”
B. “Often women become offended if asked about their safety in relationships.”
C. “It is mandatory that all women be questioned about domestic violence.”
D. “How would you feel to know that her partner is beating her and you didn’t ask?”

Correct answer: “Often women who are victims of domestic violence suffer vague symptoms such as abdominal pain.”

Rationale: The correct answer is, “Often women who are victims of domestic violence suffer vague symptoms such as abdominal pain.” There is a well-documented correlation between vague symptoms like abdominal pain and battered woman syndrome. It is crucial for healthcare providers to inquire about potential domestic violence when presented with such symptoms. Choice B is incorrect as studies show that women are not generally offended by appropriately phrased questions about their safety in relationships. While it is not mandatory to question all women about domestic violence, it is advisable to at least ask a screening question regarding safety. Choice D is inappropriate as it uses a shaming tactic, which is not constructive and may create a hostile work environment. It's important for healthcare professionals to approach sensitive topics like domestic violence with empathy and professionalism.

3. A client tells the nurse that his wife’s nagging really gets on his nerves. He asks the nurse to talk with her about her nagging during their family session tomorrow afternoon. Which of the following responses is the most therapeutic for the client?

A. “Tell me more specifically about her complaints.”
B. “Can you think of reasons why she might nag you so much?”
C. “I’ll help you think about how to bring this up yourself tomorrow afternoon.”
D. “Why do you want me to initiate this in tomorrow’s session rather than you?”

Correct answer: “I’ll help you think about how to bring this up yourself tomorrow afternoon.”

Rationale: The most therapeutic response is to empower the client to address the issue himself. By offering assistance in thinking about how to bring up the topic during the family session, the nurse is promoting the client's autonomy and communication skills. This response encourages the client to take an active role in resolving the situation. Choices A and B focus on the wife's behavior, which is not the immediate concern during this interaction. Choice D challenges the client's request and shifts the responsibility back to the client, potentially hindering progress and discouraging open communication.

4. How should Lasix be administered to prevent hypotension?

A. By administering it over 1–2 minutes
B. By hanging it IV piggyback
C. With normal saline only
D. By administering it through a venous access device

Correct answer: By administering it over 1–2 minutes

Rationale: Lasix should be administered over 1–2 minutes at approximately 1mL per minute to prevent hypotension. This slow administration helps to reduce the risk of adverse effects such as sudden drops in blood pressure. Choice B is incorrect because Lasix does not need to be hung IV piggyback, choice C is incorrect as Lasix administration does not require it to be mixed with normal saline only, and choice D is incorrect as Lasix does not have to be specifically administered through a venous access device (VAD) to prevent hypotension.

5. The client is admitted with chronic obstructive pulmonary disease. Blood gases reveal pH 7.36, CO2 45, O2 84, HCO3 28. The nurse would assess the client to be in:

A. Uncompensated acidosis
B. Compensated alkalosis
C. Compensated respiratory acidosis
D. Uncompensated metabolic acidosis

Correct answer: Compensated respiratory acidosis

Rationale: The client is experiencing compensated respiratory acidosis. The pH is within the normal range but is lower than 7.40, indicating acidity. The elevated CO2 level and low O2 level suggest respiratory involvement. The slightly elevated HCO3 level indicates a compensatory mechanism. In respiratory acidosis, the pH will be inversely related to the CO2 and bicarb levels, with elevated CO2 and HCO3 levels contributing to acidosis. Choices A, B, and D are incorrect because they do not align with the presented blood gas values and the compensatory response observed in this case.