A nurse is counseling an older adult client whose partner died suddenly the previous month. The client cries periodically and rarely makes eye contact. Which of the following questions is the priority for the nurse to ask?
"What are you looking forward to each day?"
"Can you tell me about your sleep patterns?"
"Have you ever felt like you don't want to live anymore?"
"Are you taking any medications at this time?"
The Correct Answer is C
A) "What are you looking forward to each day?": While asking about daily expectations can provide insight into the client's coping mechanisms and hopefulness, it does not immediately address potential safety concerns. It is a helpful question for assessing the client's adjustment but not the priority if there is a concern about suicidal ideation.
B) "Can you tell me about your sleep patterns?": Sleep patterns are important for understanding overall well-being, especially during grief. However, this question is secondary to addressing the immediate risk of self-harm. Assessing sleep can come after determining if the client is having suicidal thoughts.
C) "Have you ever felt like you don't want to live anymore?": This question is crucial because it directly assesses the client's risk of suicidal ideation or self-harm. Given the client's recent loss and current symptoms, it is important to evaluate if there is a risk to their safety, making this the priority question.
D) "Are you taking any medications at this time?": While it is important to know about the client's medication use, this question does not address the immediate risk of self-harm or assess the psychological impact of the recent loss. Medication information is less urgent compared to evaluating suicidal thoughts.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) Initiate frequent, short periods of exercise throughout the day: Frequent, short periods of exercise are beneficial for a client with left-sided hemiplegia. Regular movement helps maintain joint flexibility, muscle strength, and overall functional ability. This approach can prevent complications such as contractures and muscle atrophy.
B) Decrease the amount of range of motion performed if tightness occurs: If tightness occurs, rather than decreasing range of motion, it is important to address it through appropriate stretching and adjustments in exercise technique. Reducing range of motion could lead to further loss of mobility and function.
C) Perform range-of-motion exercises to the affected side once per day: Performing range-of-motion exercises only once per day is generally insufficient. To maintain or improve mobility and prevent contractures, range-of-motion exercises should be performed multiple times throughout the day, as directed by the care plan.
D) Avoid repetitive movements during exercise: Repetitive movements are not necessarily harmful and can be beneficial for improving motor function and muscle coordination. However, it is important to balance repetitive exercises with variety and adjust based on the client’s condition and tolerance.
Correct Answer is B
Explanation
A) Offer the client a small meal if she is not nauseated:
While eating a small meal can help raise blood glucose levels, it is not the immediate priority in a severe hypoglycemia situation. The client might be unconscious or unable to swallow safely, making this action inappropriate as a first step.
B) Administer 1 mg of glucagon intramuscularly to the client:
Administering glucagon intramuscularly is the most crucial initial action. Glucagon rapidly increases blood glucose levels by stimulating glycogen breakdown in the liver. This is vital for quickly reversing severe hypoglycemia, especially if the client is unconscious or unable to ingest carbohydrates orally.
C) Contact the client's provider for further instructions:
Contacting the provider is essential, but it should occur after addressing the immediate hypoglycemic episode. Once the client's condition stabilizes, further guidance can be sought from the healthcare provider.
D) Transport the client to an emergency department for treatment:
Transporting the client to the emergency department is necessary if the hypoglycemia does not improve after administering glucagon or if the client remains unresponsive. However, it is not the first action; immediate glucagon administration takes precedence to stabilize the client's condition before considering transportation.
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