A nursing diagnosis of "Risk for Deficient Fluid Volume" related to excessive ﬂuid loss, secondary to diarrhea and vomiting was implemented for a home health client who began with these symptoms 5 days ago. A goal was set that the client's symptoms would be eliminated within 48 hours. The client is being seen after a week and has had no diarrhea or vomiting for the past 5 days. What should the nurse do?

Document that the potential problem is being prevented from recurring.

Document that the problem has been resolved and the goal has been met.

Assume that whatever the cause was, the symptoms may return, but the goal was met.

Keep the problem on the care plan in case the symptoms return.

Answer and Explanation

The Correct Answer is B

The nursing diagnosis was "Risk for Deficient Fluid Volume" related to excessive ﬂuid loss, secondary to diarrhea and vomiting. The goal was set that the client's symptoms would be eliminated within 48 hours. The client is being seen after a week and has had no diarrhea or vomiting for the past 5 days, indicating that the problem has been resolved. Therefore, the nurse should document that the problem has been resolved and the goal has been met.

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Correct Answer is C

Explanation

The priority nursing diagnosis for this client should be Risk for injury related to somnambulism. Somnambulism, also known as sleepwalking, can put the client at risk for injury as they may engage in activities while not fully conscious. The client's report of falling asleep while driving and almost being involved in an accident further highlights the potential risk for injury. It is important for the nurse to address this risk and develop a plan to ensure the client's safety.

A. Democratic leader B. Situational leader C. Laissez-faire leader D. Bureaucratic leader

Correct Answer is C

Explanation

Based on the comment made by the nurse manager during the staﬀ meeting, this leader can be best identified as a laissez-faire leader. A laissez-faire leader is one who takes a hands-oﬀ approach to leadership and allows group members to make their own decisions and determine their own course of action. In this case, the nurse manager is allowing the staﬀ to come to their own decision regarding staﬀ assignments and is not actively directing or guiding the decision-making process.

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Naxlex Comprehensive Predictor Exams

The client who has sleep apnoea reports falling asleep while driving, almost being involved in an accident, and frequent episodes of sleepwalking. What nursing diagnosis should be a priority for this client?

Correct Answer is C

Explanation

During a particularly heated staﬀ meeting regarding staﬀ assignments, the nurse manager makes this comment: "When you all can come to a decision, let me know and we'll move on from there." This leader is best identified as which of the following?

Correct Answer is C

Explanation

A client needs a test to determine the amount of residual urine. The nurse realizes that this assessment is used for which reason(s)? Select all that apply.

A client visits a health care facility reporting loss of appetite following a prolonged illness. How should the nurse document the client's condition?

A nurse is caring for a client in the introductory (orientation) phase of the nurse-client relationship. Which of the following communication techniques should the nurse use during this phase?

The nurse educator provides developmental testing for kindergarten through third-grade students. Which level of prevention is the nurse performing?

The nurse is using the PED model to write a nursing diagnosis. Which nursing diagnoses demonstrate that the nurse used this model appropriately? Select all that apply.

A young man who has had a traumatic mid-thigh amputation of his right leg refuses to look at the wound during dressing changes. Which response by the nurse is appropriate?

A nurse is evaluating a nursing student's understanding of positioning clients. Which of the following statements indicates a need for further teaching?

The nurse is caring for a client who has difficulty hearing conversation. What intervention should the nurse implement?