A client, age 79 years, tells the home visiting nurse, "I've been feeling down for the last few days. I don't have much to live for. My family and friends are all dead. My money's running out, and my health is failing." The nurse should assess this as:
Normal pessimism of the elderly.
A cry for sympathy.
Normal grieving.
Evidence of high suicide potential.
The Correct Answer is D
A. Normal pessimism of the elderly: This statement downplays the seriousness of the client’s feelings. Although some elderly individuals may experience sadness, these statements suggest a deeper issue that should not be considered normal.
B. A cry for sympathy: This response dismisses the client's feelings as attention-seeking, which could lead to missing a serious issue, such as depression or suicidal ideation.
C. Normal grieving: While grief can lead to feelings of sadness, the statements indicate a broader sense of hopelessness and worthlessness, which goes beyond normal grieving.
D. Evidence of high suicide potential: The client’s statements suggest feelings of hopelessness and despair, which are red flags for suicide risk, especially in elderly clients. This requires immediate assessment and intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. client's anxiety level decreased: While reducing anxiety is important, it is not the initial priority when a client is experiencing physical pain that is affecting their ability to engage in the assessment.
B. client's pain level decreased: The initial desired outcome is to address the client's immediate physical pain. Once the pain is managed, the client will likely be better able to participate in the assessment and respond to questions about their mental health.
C. assessment completed: Completing the assessment is important, but it should not be prioritized over managing the client's immediate physical pain, which is currently hindering their ability to participate.
D. client understood the importance of the assessment: The client’s understanding of the assessment’s importance is less critical than addressing their immediate physical discomfort, which is a more pressing concern in this scenario.
Correct Answer is A
Explanation
A. Ensure that there is a complete and functional suction system at the bedside. This is an essential precaution for clients with dysphagia because they are at high risk of aspiration. Having suction equipment ready allows for quick intervention if the client begins to choke or aspirate.
B. Position the head of the client's bed at a height of 30° to 45°. This positioning is too low for feeding. To reduce the risk of aspiration, the head of the bed should be elevated to at least 45° to 90° during feeding. Therefore, this option is less safe.
C. Provide two larger meals each day rather than three smaller meals in order to prevent fatigue. Smaller, more frequent meals are generally recommended to prevent fatigue and reduce the risk of aspiration, as larger meals can be overwhelming and increase the risk of choking.
D. Encourage the client to hold her breath while she is attempting to swallow. This is not a standard or safe practice for managing dysphagia. Safe swallowing techniques typically include ensuring the client is alert, properly positioned, and eating slowly with small bites.
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