A nurse in a community health clinic is conducting an assessment of a client who has two preschool-aged children, has recently gone through a divorce, and is seeking help for managing depression.
Which of the following
Questions should the nurse ask first?
“Could you describe how you are feeling today?”
“Are you having any thoughts about hurting yourself?”
“Is there anything that makes you feel less depressed?”
“Who is available to help you?”
The Correct Answer is B
Choice A rationale
Asking the client to describe how they are feeling today is an important part of the assessment. However, when dealing with a client who is managing depression, the nurse’s first priority should be to ensure the safety of the client.
Choice B rationale
Asking if the client is having any thoughts about hurting themselves is the first question the nurse should ask. This is because safety is always the top priority, and clients dealing with depression may be at risk for self-harm or suicide.
Choice C rationale
While it’s important to understand what makes the client feel less depressed, this question is not as immediately critical as assessing for potential self-harm or suicide risk.
Choice D rationale
Understanding the client’s support system is an important part of the assessment, but it is not the first priority. The nurse’s initial focus should be on assessing the client’s immediate safety and mental health status.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
While it is true that many patients who choose hospice care have declined additional life- prolonging treatments, this is not a requirement for eligibility. Some patients may still pursue certain treatments while receiving hospice care.
Choice B rationale
The need for inpatient care due to lack of a caregiver does not determine eligibility for hospice care. Hospice care can be provided in various settings, including the patient’s home, a hospice facility, or a long-term care facility.
Choice C rationale
While insurance coverage can influence access to hospice care, it is not a condition for medical eligibility. The decision for hospice care is based on the patient’s health status and not on their insurance coverage.
Choice D rationale
This is the correct answer. To be eligible for hospice care, a patient must have a prognosis of six months or less to live if the illness runs its normal course.
Correct Answer is D
Explanation
Choice A rationale
The statement about only going to the hospital if the client stops breathing is incorrect. Palliative care is not limited to end-of-life care and does not restrict hospital visits to only life- threatening situations. It is a comprehensive approach to treatment that focuses on improving quality of life for patients and their families, addressing physical, psychosocial, and spiritual problems.
Choice B rationale
The statement about needing to stop treatments for cancer before beginning palliative care is incorrect. Palliative care can be provided alongside curative treatment and is not dependent on the cessation of other treatments. It is designed to alleviate symptoms and improve quality of life at any stage of illness, not just at the end of life.
Choice C rationale
The statement about having about 6 months or less to live if the oncologist recommends palliative care is incorrect. Palliative care is not only for end-of-life situations. It can be introduced at any stage of illness, even at the same time as treatment aimed at curing the disease. The goal of palliative care is to improve quality of life by providing relief from the symptoms and stress of the illness.
Choice D rationale
The statement about the purpose of palliative care being to provide comfort measures for cancer is correct. Palliative care aims to relieve symptoms and improve the quality of life for patients with serious illnesses, including advanced-stage lung cancer. It can help manage
symptoms such as pain, shortness of breath, fatigue, nausea, loss of appetite, problems with sleep, and emotional issues like anxiety and depression.
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