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?"
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Pulmonary tuberculosis. This is correct because tuberculosis is a highly contagious airborne disease that must be reported to the health department for tracking, treatment, and public health intervention.
B. Fibromyalgia syndrome. This is incorrect because fibromyalgia is a chronic pain condition that is not infectious and does not require mandatory reporting.
C. Herpes simplex virus. This is incorrect because herpes simplex, though contagious, is not a reportable disease.
D. Methicillin-resistant Staphylococcus aureus. This is incorrect because MRSA infections are not universally required to be reported, though some states may have specific regulations for outbreaks in healthcare settings.
Correct Answer is B
Explanation
A. Protective environment. This is incorrect because a protective environment is used for immunocompromised clients, not for those with bacterial meningitis.
B. Droplet. This is correct because bacterial meningitis is transmitted through respiratory secretions. Droplet precautions, including wearing a mask when within 3 to 6 feet of the client, are necessary to prevent the spread of infection.
C. Contact. This is incorrect because bacterial meningitis is not primarily transmitted through direct contact with surfaces or bodily fluids, making contact precautions unnecessary.
D. Airborne. This is incorrect because bacterial meningitis does not spread through airborne particles that remain suspended in the air, so airborne precautions are not required.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.