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?"

Answer and Explanation

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.

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Correct Answer is B

Explanation

Rationale:

A. Levothyroxine is used to treat hypothyroidism, not hyperthyroidism. In a Thyroid storm, thyroid hormone levels are already dangerously elevated. Giving levothyroxine would worsen the condition and increase metabolic demand further.

B. Thyroid storm causes a severe hypermetabolic state, increasing oxygen consumption and demand. Supplemental oxygen helps; prevent hypoxia, support tissues under metabolic stress, reduce risk of organ failure. Therefore making it an important supportive, priority intervention.

C. Clients in thyroid storm typically have high fever (hyperthermia). The appropriate intervention is cooling measures (cooling blankets, antipyretics), not warming. Warm blankets would worsen hyperthermia.

D. Thyroid storm causes tachycardia (very fast heart rate) and risk of arrhythmias. Increasing the pulse rate would increase risk of complications such as heart failure. Therefore the goal is to decrease heart rate (e.g., beta-blockers) and reduce cardiac workload

A. Place the client in a semi-Fowler's position, B. Infuse warm IV fluids. C. Assess the client's skin hourly when using a heating blanket. D. Rewarm the client's extremities first.

Correct Answer is B

Explanation

A) Place the client in a semi-Fowler's position:
While positioning can be beneficial for various conditions, it does not directly address the core issue of hypothermia. Rewarming the client effectively is the primary concern in hypothermia management.

B) Infuse warm IV fluids:
Administering warm IV fluids is a crucial intervention for moderate hypothermia as it helps increase the client's core body temperature more rapidly and effectively. This method ensures that the body's internal temperature is raised, which is vital for stabilizing the client.

C) Assess the client's skin hourly when using a heating blanket:
Monitoring the skin is important to prevent burns or skin damage from a heating blanket, but it is a supportive measure rather than a primary intervention. The key priority is to rewarm the client’s core.

D) Rewarm the client's extremities first:
Rewarming the extremities first can actually be harmful in hypothermia, as it can lead to a drop in core body temperature due to the return of cold blood from the periphery to the core (afterdrop). The focus should be on warming the core body first.

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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?

Nursing Test Bank

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