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?"
"Do you ever think about harming yourself?"
"How long have you had these feelings of uselessness?"
"Would you tell me more about the changes you see in your body?"
The Correct Answer is B
A. "Did anything in particular make you feel this way?" - While exploring potential triggers for the client's feelings of uselessness is important, assessing for suicidal ideation takes precedence. However, this question can be asked after addressing the immediate safety concern.
B. "Do you ever think about harming yourself?" - This is the priority assessment question. Older adults experiencing feelings of uselessness and worthlessness may be at risk for suicidal ideation or self-harm. Asking about thoughts of self-harm allows the nurse to assess the client's safety and determine the need for immediate intervention.
C. "How long have you had these feelings of uselessness?" - While understanding the duration of the client's feelings is relevant, assessing for suicidal ideation is more critical in ensuring the client's safety.
D. "Would you tell me more about the changes you see in your body?" - Exploring the client's perception of physical changes is important for addressing body image concerns and promoting self-esteem. However, assessing for suicidal ideation takes precedence as it addresses the client's immediate safety.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Answer: A
Rationale:
A. Frequent swallowing: Frequent swallowing in a postoperative tonsillectomy patient can be a sign of bleeding or a hemorrhage. This is a priority finding because it may indicate that the child is swallowing blood, which requires immediate intervention to prevent significant blood loss and complications.
B. Dark brown emesis: Dark brown emesis can be a normal finding post-tonsillectomy, as it may indicate the presence of old blood or clotted blood. While it should be monitored, it is not as urgent as frequent swallowing, which may signify active bleeding.
C. Sore throat: A sore throat is a common postoperative symptom following a tonsillectomy and is generally expected. It is important to manage pain and discomfort, but it is not as urgent as signs of potential bleeding.
D. Blood-tinged mucus: Blood-tinged mucus can occur after a tonsillectomy due to irritation or minor bleeding. While it should be observed, it is less critical compared to frequent swallowing, which may indicate more significant bleeding.
Correct Answer is B
Explanation
A. Establish a new routine for the child to follow while in the facility. - Preschoolers thrive on routines and familiarity, especially in unfamiliar environments like acute care facilities. Therefore, it's essential for the nurse to maintain the child's existing routine as much as possible to provide a sense of security and stability.
B. Encourage the child to play with toys such as a pounding board. - Encouraging play with age-appropriate toys helps promote normalcy, reduce anxiety, and facilitate coping for preschoolers during their hospital stay. Toys like a pounding board provide opportunities for physical activity and engagement, which can help distract and entertain the child.
C. Use medical terminology when discussing procedures with the child. - Preschoolers have limited understanding of complex medical terminology. Using simple, age-appropriate language helps the child better comprehend what is happening, reducing fear and anxiety. Therefore, it's important for the nurse to avoid medical jargon and use language the child can understand.
D. Perform the morning assessments when the parent is not in the room. - Preschoolers often feel more comfortable and secure when their parents are present, especially in unfamiliar environments like hospitals. Performing assessments in the presence of the parent helps maintain the child's sense of security and allows the parent to participate in the child's care and provide comfort and support.
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