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.

Answer and Explanation

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.

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Correct Answer is ["A","C","D"]

Explanation

A. Unequal pupils: Unequal pupils (anisocoria) can indicate a potential neurological issue, such as intracranial pressure or brain injury, especially after trauma. It is a significant finding requiring further evaluation.

B. Pupil reaction quick: Quick pupil reaction is typically normal and indicates proper neurological function, not a concern.

C. Pinpoint pupils: Pinpoint pupils can indicate opioid overdose or certain types of brainstem injury and should be evaluated as a potential neurological concern.

D. Absence of pupillary response: Absence of pupillary response to light can be a serious neurological concern, indicating severe brain injury or significant neurological compromise.

E. Pupil reacts to light: A pupil that reacts to light is a normal finding and indicates proper neurological function.

A. Prothrombin level B. Chest x-ray C. Brain CT scan or MRI D. Lumbar puncture

Correct Answer is C

Explanation

A. Prothrombin level: Although checking coagulation levels like prothrombin time may be important, it is not the first-line diagnostic tool for determining the type of stroke (ischemic or hemorrhagic), which is critical for treatment decisions.

B. Chest x-ray: A chest x-ray is not directly related to diagnosing or determining the type of stroke. It may be used for other purposes, such as assessing for respiratory issues, but it is not the priority in stroke diagnosis.

C. Brain CT scan or MRI: A brain CT scan or MRI is the most crucial diagnostic test to perform before initiating treatment for a stroke. This imaging helps differentiate between ischemic and hemorrhagic stroke, guiding the appropriate treatment approach.

D. Lumbar puncture: A lumbar puncture may be used in certain neurological evaluations but is not the first-line test for diagnosing a stroke. It is invasive and not typically performed in the acute setting for stroke evaluation.

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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:

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Naxlex Comprehensive Predictor Exams

The nurse is assessing the client's pupils following a sports injury. Which of the following assessment findings indicates a neurologic concern? Select all that apply.

Correct Answer is ["A","C","D"]

Explanation

A client is brought to the emergency department with symptoms of a cerebrovascular accident (CVA). The nurse would anticipate which diagnostic evaluation to be completed prior to initiation of treatment?

Correct Answer is C

Explanation

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