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?"

Answer and Explanation

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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Correct Answer is C

Explanation

A. Plan for your son to meet his sister for the first time at home. This is incorrect because allowing the sibling to visit the newborn in the hospital can help with early bonding and ease the transition.
B. Give your son plenty of "alone time" with his sister. This is incorrect because young children require supervision around infants to ensure safety.
C. Give your son a little gift from his new sister. This is correct because presenting a small gift from the baby helps the older sibling feel included and fosters a positive association with the new arrival.
D. Hold your daughter when your son first meets her. This is incorrect because allowing the older sibling to greet the parent first before introducing the baby can help them feel reassured and less displaced.

A. "I will turn the car seat forward facing when my baby is 1 year old." B. "I will place the retainer clip on my baby's upper abdomen." C. "I will position the shoulder harness straps 3 inches above my baby's shoulders." D. "I will position my baby at a 45-degree angle in the car seat."

Correct Answer is D

Explanation

A. I will turn the car seat forward facing when my baby is 1 year old. This is incorrect because the American Academy of Pediatrics recommends keeping infants in a rear-facing car seat until at least 2 years of age or until they reach the maximum height and weight limit specified by the car seat manufacturer.
B. I will place the retainer clip on my baby's upper abdomen. This is incorrect because the retainer clip should be positioned at armpit level to properly secure the straps and protect the baby in case of a collision.
C. I will position the shoulder harness straps 3 inches above my baby's shoulders. This is incorrect because for a rear-facing car seat, the shoulder harness straps should be positioned at or just below the infant’s shoulders, not above.
D. I will position my baby at a 45-degree angle in the car seat. This is correct because positioning the baby at a 45-degree angle helps maintain an open airway and prevents airway obstruction due to the head falling forward.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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