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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Breathlessness is not a typical symptom of a sliding hiatal hernia. However, in severe cases, large hernias may cause shortness of breath due to pressure on the diaphragm.
B. Heartburn (acid reflux) is a common symptom because the hernia allows stomach acid to move up into the esophagus, causing irritation and discomfort.
C. Abdominal cramping is not a primary symptom of a sliding hiatal hernia. Cramping is more commonly associated with gastrointestinal conditions like irritable bowel syndrome (IBS) or gastroenteritis.
D. Constipation is not directly linked to a sliding hiatal hernia. Instead, symptoms usually involve gastroesophageal reflux disease (GERD)-related issues, such as heartburn and regurgitation.
Correct Answer is D
Explanation
A. "You can take this medication with milk." This is incorrect because dairy products interfere with the absorption of tetracycline and should be avoided when taking the medication.
B. "You should take this medication at bedtime." This is incorrect because taking tetracycline at bedtime increases the risk of esophageal irritation. It should be taken with a full glass of water while sitting or standing upright.
C. "Constipation is an adverse effect of this medication." This is incorrect because tetracycline is more commonly associated with diarrhea rather than constipation.
D. "Light sensitivity is an adverse effect of this medication." This is correct because tetracycline can cause photosensitivity, making the skin more susceptible to sunburn. Clients should be advised to use sunscreen and wear protective clothing when exposed to sunlight.
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