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 A
Explanation
A. Hematologic spread: Hematologic spread (through the bloodstream) is a common mechanism for metastasis to distant organs like bones and liver. This is the most likely mechanism for the spread described.
B. Lymphatic circulation: Lymphatic spread often leads to regional lymph nodes rather than distant organs like bones and liver.
C. Invasion: Invasion involves local spread into adjacent tissues but does not typically account for distant metastasis.
D. Angiogenesis: Angiogenesis refers to the formation of new blood vessels to supply the tumor, not the mechanism by which cancer cells spread to distant sites.
Correct Answer is A
Explanation
A. Drink adequate noncaffeinated and non-alcoholic beverages: Xerostomia (dry mouth) can be alleviated by staying hydrated with noncaffeinated and non-alcoholic beverages, which help to moisten the mouth and improve comfort.
B. Take nutrient-dense foods or to combine plant-based proteins: While nutrient-dense foods are important for overall health, they do not specifically address the issue of xerostomia. Plant-based proteins do not directly impact the symptoms of dry mouth.
C. Take protein-based liquid supplements: Protein-based liquid supplements are not specifically designed to address dry mouth and may not help in alleviating xerostomia.
D. Get dental care and practice dental hygiene daily: While dental care and hygiene are important for overall oral health, they do not specifically address xerostomia. Drinking fluids is more directly helpful for managing dry mouth.
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