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Clinical Nurse Specialist CNS Adult Practice Test

Category - AACN Clinical Nurse Specialist Practice Test

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Nina the New Nurse has assessed a new client, admitted for sudden altered level of consciousness (ALOC). She also reviewed the current lab results, which are as follows:
Na+ 156
CL- 100
K+ 4.0
HCO 21
BUN 86
Bld. Glucose 100

Nina the New Nurse is entering a nursing diagnosis on the care plan based on the information she has gathered. Which nursing diagnosis is most appropriate?
  1. Fluid volume deficit.
  2. Self-care deficit: feeding.
  3. Alteration in urinary elimination.
  4. Trick question! There isn’t enough information provided in the above scenario to determine a nursing diagnosis!
Explanation
Answer: A - The lab results reveal an elevated Na+ and BUN, and decreased HCO. Na+ and BUN are increased when a client is dehydrated. When assessing findings, you must first determine if the results are normal or abnormal, then consider what your findings may indicate and how that affects the development of the nursing diagnosis.
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