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 D
Explanation
A. Tachypnea. Rapid breathing is associated with diabetic ketoacidosis (DKA) rather than mild hypoglycemia.
B. Ketonuria. The presence of ketones in the urine occurs with prolonged hyperglycemia and DKA, not with hypoglycemia.
C. Warm skin. Hypoglycemia typically causes cool, clammy skin due to sympathetic nervous system activation, not warmth.
D. Nervousness. Low blood glucose triggers the release of epinephrine, leading to symptoms such as nervousness, tremors, and sweating.
Correct Answer is C
Explanation
A. Have the client hold their breath during the examination. This is not recommended, as slow, deep breathing helps the client relax and reduces discomfort.
B. Ensure that the client's bladder is full. The bladder should be emptied before the exam to enhance comfort and allow better access for the provider.
C. Instruct the client to bear down when the speculum is inserted. This helps relax the pelvic muscles and makes insertion easier, reducing discomfort.
D. Place the client in modified Sims' position. The lithotomy position is the correct positioning for a pelvic examination, not modified Sims'.
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