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 ["10"]
Explanation
ML
The formula to calculate the IV flow rate is:
mL/hr =
(Desireddose(units/hr)×Totalvolume(mL))/ Available dose
Substituting the given values:
(1,000×250)/25000
= 250,000/25,000
= 10ml/hr
Correct Answer is C
Explanation
A. "I will take the medication in the morning." Metformin extended-release can be taken once daily, but it is usually recommended with the evening meal to improve gastrointestinal tolerance.
B. "I will take the medication on an empty stomach." This is incorrect because metformin should be taken with food to reduce gastrointestinal side effects such as nausea and diarrhea.
C. "I will avoid crushing this medication." This is correct because extended-release tablets should not be crushed, split, or chewed, as this can alter the drug’s release mechanism.
D. "I will expect to gain weight." Metformin is not associated with weight gain; in fact, it may cause modest weight loss in some clients.
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