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. Minimizing distractions helps children with ADHD focus better and improves concentration.
B. Writing by hand does not necessarily enhance concentration and may actually increase frustration for some children with ADHD.
C. A structured and predictable routine is beneficial for children with ADHD, so varying activities daily may be counterproductive.
D. Encouraging a child to read during an outdoor activity period may limit needed physical movement, which can help manage ADHD symptoms.
Correct Answer is C
Explanation
A. The guardian wants to accompany the child from the ED to the radiology department. This is a typical parental response and does not indicate maltreatment. Parents often want to stay with their child for reassurance.
B. The guardian states the child fell off the swing in the backyard. This is a plausible explanation for an injury in a preschooler, though the consistency of the story with the injury should still be assessed.
C. The child was brought to the ED 2 days after the injury occurred. A delay in seeking medical care for a significant injury is a potential warning sign of child maltreatment and warrants further investigation.
D. The child cries loudly when their arm is moved or manipulated. Pain with movement is expected with a fracture and does not indicate maltreatment.
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