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.
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Related Questions
Correct Answer is D
Explanation
A. Varicella vaccine is given at 12–15 months and a second dose at 4–6 years. It is not given at 2 months.
B. Influenza vaccine is recommended annually starting at 6 months of age. It is not given at 2 months.
C. Hepatitis A vaccine is given at 12–23 months, with a second dose 6 months later. It is not given at 2 months.
D. Rotavirus vaccine is routinely given at 2 months and again at 4 months (and possibly 6 months depending on the vaccine type). This is the correct answer.
Correct Answer is C
Explanation
A. Decaffeinated coffee is not recommended for clients with GERD because it can still increase gastric acid secretion, which may worsen symptoms.
B. Tomato soup is acidic and can trigger acid reflux, making it an unsuitable choice for clients with GERD.
C. White fish is a low-fat, non-acidic protein source that is unlikely to trigger GERD symptoms, making it an appropriate dietary choice.
D. Hot cocoa contains chocolate and caffeine, both of which can relax the lower esophageal sphincter (LES) and increase acid reflux.
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