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 D

Explanation

A. Contact precautions are used for infections transmitted by direct or indirect contact with the client or their environment. Examples include MRSA, C. difficile, and other multidrug-resistant organisms.
B. Airborne precautions are used for infections transmitted by small droplets that remain suspended in the air and can be inhaled. Examples include tuberculosis (TB), measles, and chickenpox (varicella).
C. Protective environment precautions are typically used for clients with compromised immune systems, such as those undergoing stem cell transplants, to protect them from environmental pathogens.
D. Droplet precautions are used for infections transmitted by large respiratory droplets that can travel up to approximately 3 feet. Examples include bacterial meningitis, influenza, and pertussis. Therefore, the nurse should initiate droplet precautions for the school-age child with bacterial meningitis.

A. Take antacids that contain mint for heartburn. B. Avoid consuming foods containing chocolate. C. Increase dietary intake of citrus fruits. D. Lie down for 30 min after eating a meal.

Correct Answer is B

Explanation

A. Take antacids that contain mint for heartburn. - This statement is incorrect. While antacids can help neutralize stomach acid and relieve heartburn symptoms, antacids containing mint can relax the lower esophageal sphincter (LES), leading to increased reflux symptoms. Therefore, clients with GERD should avoid antacids containing mint.
B. Avoid consuming foods containing chocolate. - This statement is correct. Chocolate is a common trigger for GERD symptoms due to its high fat content, which can relax the LES and delay stomach emptying, leading to increased acid reflux. Advising the client to avoid foods containing chocolate can help minimize GERD symptoms.
C. Increase dietary intake of citrus fruits. - This statement is incorrect. Citrus fruits are acidic and can exacerbate GERD symptoms by increasing stomach acid production and irritating the esophagus. Therefore, clients with GERD should limit or avoid citrus fruits to reduce acid reflux.
D. Lie down for 30 min after eating a meal. - This statement is incorrect. Lying down after eating can worsen GERD symptoms by allowing stomach acid to flow back into the esophagus more easily. Instead, clients with GERD should remain upright for at least 2-3 hours after eating to help prevent acid reflux.

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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

A nurse is admitting a school-age child who has bacterial meningitis. Which of the following types of isolation precautions should the nurse initiate?

Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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