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?"

Answer and Explanation

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.

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Correct Answer is B

Explanation

Answer: B

Rationale:

A) Request insertion of a tracheostomy tube: The high-pressure alarm on a ventilator typically indicates increased resistance to airflow within the airway, which may be due to secretions, bronchospasm, or another obstruction. Requesting insertion of a tracheostomy tube is not the first action the nurse should take in response to a high-pressure alarm. Instead, the nurse should assess and manage potential causes of increased airway resistance before considering a change in airway management.

B) Suction the client's airway: Suctioning the client's airway is the priority action in response to a high-pressure alarm on the ventilator. Increased airway pressure may be due to secretions or a mucus plug, leading to airway obstruction. Suctioning helps clear the airway and restore effective ventilation.

C) Tighten the tubing connections: While loose tubing connections can contribute to air leaks and decreased ventilation efficiency, they are not the primary cause of a high-pressure alarm. Tightening tubing connections may be necessary but is not the initial action in response to a high-pressure alarm.

D) Look for a leak in the tube's cuff: Checking for a leak in the endotracheal tube cuff is essential to ensure an adequate seal and prevent aspiration. However, it is not the first action the nurse should take in response to a high-pressure alarm. The priority is to address potential airway obstruction by suctioning the client's airway to remove secretions or other obstructions.

A. Hazelnuts B. Almonds C. Bananas D. Strawberries

Correct Answer is C

Explanation

A. Hazelnuts: While hazelnuts are a common allergen, they are not typically associated with cross-sensitivity to latex. Therefore, further assessment for cross-sensitivity to hazelnuts is not necessary based solely on the child's latex allergy.
B. Almonds: Similar to hazelnuts, almonds are a common allergen but are not typically associated with cross-sensitivity to latex. Therefore, further assessment for cross-sensitivity to almonds is not necessary based solely on the child's latex allergy.
C. Bananas: Bananas are one of the most common foods associated with latex allergy cross-sensitivity. Many individuals with latex allergy may also experience allergic reactions to bananas due to shared allergenic proteins. Therefore, further assessment for cross-sensitivity to bananas is warranted in this case.
D. Strawberries: While strawberries are a common allergen, they are not typically associated with cross-sensitivity to latex. Therefore, further assessment for cross-sensitivity to strawberries is not necessary based solely on the child's latex allergy.

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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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