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

Explanation

A. Polyuria. Increased urination is not a common adverse effect of clozapine and does not require immediate reporting.
B. Fever. Clozapine can cause agranulocytosis, a serious condition that suppresses white blood cell production. Fever may indicate infection, which requires immediate evaluation.
C. Diarrhea. Gastrointestinal symptoms can occur with clozapine but are not typically urgent unless severe or persistent.
D. Diaphoresis. Excessive sweating is a possible side effect but does not require immediate medical attention.

A. Recreased impulsiveness B. Decreased abdominal pain C. Increased appetite D. Increased urine output

Correct Answer is A

Explanation

A. Decreased impulsiveness. Methylphenidate is a CNS stimulant used to treat ADHD. It helps improve attention, focus, and impulse control, which indicates the medication's effectiveness.

B. Decreased abdominal pain. Abdominal pain is a possible side effect of methylphenidate, but its resolution does not indicate the medication’s effectiveness in treating ADHD.

C. Increased appetite. Methylphenidate commonly suppresses appetite rather than increasing it. Increased appetite would not indicate effectiveness.

D. Increased urine output. Methylphenidate does not significantly affect urine output, so this is not a sign of its effectiveness.

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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

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