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
A. Report sudden, persistent headaches: Sudden, persistent headaches can indicate a sickle cell crisis or complications such as stroke. Prompt reporting of these symptoms allows for timely intervention and management of potential complications.
B. Avoid meningococcal immunizations: Immunizations, including meningococcal vaccines, are essential for individuals with sickle cell anemia because they are at increased risk of infections, including those caused by encapsulated bacteria like Neisseria meningitidis. Immunizations help prevent serious infections and their complications.
C. Apply cold compresses to painful areas: Cold compresses are not recommended for individuals with sickle cell anemia. Heat therapy is typically used to alleviate pain associated with vaso-occlusive crises, which are common in sickle cell disease. Heat helps relax muscles and improve blood flow to the affected area, reducing pain and promoting healing.
D. Restrict fluid intake during times of stress: Individuals with sickle cell anemia should maintain adequate hydration at all times, especially during periods of stress or illness. Dehydration can exacerbate sickling of red blood cells and increase the risk of vaso-occlusive crises. Therefore, fluid intake should be encouraged, and restrictions should be avoided unless specifically advised by a healthcare provider.
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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