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 D
Explanation
A. Iron: Iron supplements are not typically contraindicated with spironolactone use. Spironolactone is a potassium-sparing diuretic and may lead to hyperkalemia, but iron supplements are not directly associated with this risk.
B. Calcium: Calcium supplements are not typically contraindicated with spironolactone use. However, calcium supplements should be taken separately from spironolactone to avoid potential interactions that may reduce the absorption of both medications.
C. Magnesium: Magnesium supplements are not typically contraindicated with spironolactone use. However, magnesium-containing antacids should be used with caution due to the potential for increased magnesium levels in the body, especially in individuals with impaired renal function.
D. Potassium: Spironolactone is a potassium-sparing diuretic, meaning it helps retain potassium in the body. Concurrent use of potassium supplements or foods high in potassium can lead to hyperkalemia when combined with spironolactone. Therefore, the client should avoid potassium supplements while taking spironolactone to prevent this risk.
Correct Answer is B
Explanation
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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