A nurse in a provider's office is talking with an older adult client who tells the nurse that they fear they are "aging badly" and feel "so useless." Which of the following assessment questions is the nurse's priority?

"Did anything in particular make you feel this way?"

"Would you tell me more about the changes you see in your body?"

"Do you ever think about harming yourself?"

"How long have you had these feelings of uselessness?"

Answer and Explanation

The Correct Answer is C

A. "Did anything in particular make you feel this way?" Understanding the cause of the client’s feelings is important, but assessing for immediate safety takes priority.
B. "Would you tell me more about the changes you see in your body?" Exploring the client’s perception of aging is useful, but it does not address potential risk for self-harm.
C. "Do you ever think about harming yourself?" This is the priority assessment question because feelings of worthlessness can indicate depression, which increases the risk of suicide in older adults. Assessing for self-harm ensures immediate safety.
D. "How long have you had these feelings of uselessness?" Identifying the duration of these feelings is relevant, but it is secondary to determining whether the client is at risk for self-harm.

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Correct Answer is ["B","C","E"]

Explanation

A. Insert an NG tube for a client who requires enteral feedings. This is incorrect because inserting an NG tube requires assessment and skill beyond the scope of practice of assistive personnel. This task should be performed by a nurse.
B. Record a client's intake after each meal. This is correct because recording intake is a non-clinical task within the scope of an assistive personnel’s role.
C. Obtain a client's vital signs every 4 hr. This is correct because measuring and documenting vital signs is a standard duty that assistive personnel can perform.
D. Instruct a client on the use of an incentive spirometer. This is incorrect because client education is a nursing responsibility and cannot be delegated to assistive personnel.
E. Transfer a client to physical therapy. This is correct because assistive personnel can safely assist with client transfers as long as no clinical judgment is required.

A. Initiate an IV infusion of lactated Ringer's. B. Place the client in a left lateral position. C. Monitor blood pressure every hour. D. Maintain continuous monitoring of the FHR.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"}}

Explanation

Anticipated Interventions:

Initiate an IV infusion of lactated Ringer's
Place the client in a left lateral position
Maintain continuous monitoring of the FHR

Contraindicated Intervention:

Monitor blood pressure every hour

Rationale:

Initiate an IV infusion of lactated Ringer’s: Hydration is important for labor progression and maternal hemodynamic stability, especially considering the client has a history of chronic hypertension and gestational diabetes.
Place the client in a left lateral position: This improves uteroplacental perfusion, helping to optimize fetal oxygenation.
Maintain continuous monitoring of the FHR: The presence of meconium-stained amniotic fluid and an elevated FHR (165/min) suggests potential fetal distress, warranting continuous fetal monitoring.
Monitor blood pressure every hour (Contraindicated): The client has chronic hypertension and gestational diabetes, both of which increase the risk for complications like preeclampsia and fetal distress. More frequent BP monitoring (e.g., every 15-30 minutes) is necessary to detect any abnormalities early.

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A nurse in a provider's office is talking with an older adult client who tells the nurse that they fear they are "aging badly" and feel "so useless." Which of the following assessment questions is the nurse's priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning assignments for the upcoming shift. Which of the following tasks should the nurse delegate to an assistive personnel? (Select all that apply.)

Correct Answer is ["B","C","E"]

Explanation

A nurse in an antepartum unit is caring for a client. Exhibits For each potential intervention, click to specify if the intervention is anticipated or contraindicated for the client.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"}}

Explanation

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