A client, age 79 years, tells the home visiting nurse, "I've been feeling down for the last few days. I don't have much to live for. My family and friends are all dead. My money's running out, and my health is failing." The nurse should assess this as:

Normal pessimism of the elderly.

A cry for sympathy.

Normal grieving.

Evidence of high suicide potential.

Answer and Explanation

The Correct Answer is D

A. Normal pessimism of the elderly: This statement downplays the seriousness of the client’s feelings. Although some elderly individuals may experience sadness, these statements suggest a deeper issue that should not be considered normal.

B. A cry for sympathy: This response dismisses the client's feelings as attention-seeking, which could lead to missing a serious issue, such as depression or suicidal ideation.

C. Normal grieving: While grief can lead to feelings of sadness, the statements indicate a broader sense of hopelessness and worthlessness, which goes beyond normal grieving.

D. Evidence of high suicide potential: The client’s statements suggest feelings of hopelessness and despair, which are red flags for suicide risk, especially in elderly clients. This requires immediate assessment and intervention.

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Correct Answer is D

Explanation

A. Grab bars: Grab bars are useful for preventing falls in the bathroom but are unrelated to the client’s atrophy of olfactory organs, which affects the sense of smell.

B. Nonslip mats: Nonslip mats can help prevent falls but are not related to the client’s diminished sense of smell.

C. Baseboard heaters: Baseboard heaters are unrelated to olfactory atrophy and do not address the safety concerns associated with a reduced sense of smell.

D. A smoke detector: A smoke detector is essential for this client because the atrophy of olfactory organs means the client may not be able to detect the smell of smoke, increasing the risk of not noticing a fire.

A. Tremors, headache, flushed face, and hallucinations B. Psychomotor hypoactivity, hypotension, and increased appetite C. Hypomania, bradycardia, and generalized seizures D. Anhidrosis, hypotonicity, and delusions

Correct Answer is A

Explanation

A. Tremors, headache, flushed face, and hallucinations: Acute alcohol withdrawal commonly presents with tremors, headache, flushed face, and hallucinations. These symptoms are characteristic of withdrawal syndrome and are important to monitor.

B. Psychomotor hypoactivity, hypotension, and increased appetite: Psychomotor hypoactivity and increased appetite are not typical symptoms of acute alcohol withdrawal. Hypotension may occur, but it is not the most prominent symptom.

C. Hypomania, bradycardia, and generalized seizures: Hypomania and bradycardia are not typical for alcohol withdrawal. Generalized seizures can occur in severe cases of withdrawal (delirium tremens), but hypomania is not a common symptom.

D. Anhidrosis, hypotonicity, and delusions: Anhidrosis (lack of sweating) and hypotonicity (decreased muscle tone) are not typical for alcohol withdrawal. Delusions may occur but are not the primary symptoms.

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A client, age 79 years, tells the home visiting nurse, "I've been feeling down for the last few days. I don't have much to live for. My family and friends are all dead. My money's running out, and my health is failing." The nurse should assess this as:

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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