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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

Answer: B

Rationale:

A) Activate the fire alarm system:

While activating the fire alarm system is essential in alerting everyone to the fire, the immediate safety of the clients must be prioritized first. Ensuring clients are safe from potential harm should precede alerting others.

B) Evacuate clients from the area:

Evacuating clients from the area is the first priority as it directly ensures their safety. In the event of a fire, removing individuals from the source of danger is crucial to prevent injury or harm.

C) Obtain and use a fire extinguisher:

Using a fire extinguisher to put out the fire is important, but it should not be the first action. Ensuring clients are evacuated to safety must take precedence before attempting to control the fire.

D) Close the doors and windows on the unit:

Closing doors and windows can help contain the fire and smoke, but this should follow the evacuation of clients. The primary concern is to get clients to a safe area first before taking measures to contain the fire.

A. Observe the client for 1 hr after meals. B. Obtain the client's vital signs every other day. C. Weigh the client every 48 hr. D. Allow the client to eat meals in their room.

Correct Answer is A

Explanation

Observe the client for 1 hr after meals: This action is appropriate during the first week of care for a client with anorexia nervosa to monitor for signs of refeeding syndrome, such as electrolyte imbalances or hypoglycemia, which can occur after meals. Continuous observation allows for prompt intervention if complications arise.
B. Obtain the client's vital signs every other day: Vital signs should be monitored more frequently, especially during the initial phase of care, to assess for any physiological changes associated with refeeding or complications of anorexia nervosa.
C. Weigh the client every 48 hr: Weighing the client every 48 hours may not provide sufficient monitoring during the first week, as weight changes can occur rapidly in clients with anorexia nervosa. Daily weights are typically recommended during the initial phase of treatment.
D. Allow the client to eat meals in their room: Allowing the client to eat meals in their room may contribute to further isolation and avoidance of social interaction, which can exacerbate symptoms of anorexia nervosa. It's important to encourage meal consumption in a supportive environment, such as a dining area, where the client can receive encouragement and monitoring from staff and peers.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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 charge nurse observes smoke coming from a trash receptacle in the unit's waiting room. Which of the following actions should the nurse take first?

Correct Answer is B

Explanation

A nurse in an acute care facility is caring for a client who has anorexia nervosa. During the first week of care, which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is teaching a client who has generalized anxiety disorder about ways to help manage stress. Which of the following instructions should the nurse give the client about using progressive relaxation?

A nurse is caring for a client who is taking disulfiram for alcohol use disorder and reports ingestion of alcohol. For which of the following adverse effects should the nurse monitor?

A nurse is caring for a client who has deep-vein thrombosis and a new prescription for antiembolic stockings. Which of the following actions should the nurse take?

A nurse is caring for a client who is 2 days postpartum. Which of the following findings should the nurse report to the provider?

A nurse is teaching a newly licensed nurse about advance directives. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

A nurse is planning care for a client who is undergoing brachytherapy with a low-dose radiation implant for treatment of prostate cancer. Which of the following interventions should the nurse include in the client's plan of care?

A nurse is developing a plan of care for a child who is in skeletal traction following a femur fracture. Which of the following actions should the nurse include in the plan?

A nurse is caring for a preschooler who is in an acute care facility. Which of the following actions should the nurse take?