A nurse in a community health clinic is assessing a client who has two preschoolers, was recently divorced, and is seeking help for managing depression. Which of the following questions should the nurse ask first?
"Are you having any thoughts about hurting yourself?"
"Who is available to help you?"
"Could you describe how you are feeling today?"
"Is there anything that makes you feel less depressed?"
The Correct Answer is A
The correct answer is choice A, "Are you having any thoughts about hurting yourself?" This is the most important question to ask because it assesses the client's risk for suicide, which is a potential complication of depression. The nurse should ask this question before exploring other issues related to the client's depression. If the client expresses suicidal thoughts or intent, the nurse should initiate appropriate interventions to ensure the client's safety.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
When discussing electrical hazards with a client, the nurse should include the statement "You should limit your use of extension cords." Extension cords can be a tripping hazard and may cause electrical shocks or fires if used improperly. The nurse should also recommend using surge protectors and avoiding overloading electrical outlets. The client should be advised to unplug electrical items by pulling on the plug, not the cord, and to avoid using electrical items near water.
Correct Answer is D
Explanation
Children with leukemia are at risk for developing oral mucositis, which is inflammation and ulceration of the oral mucosa due to the destruction of rapidly dividing cells by chemotherapy. Inspecting the child's mouth for sores and providing appropriate mouth care is essential to prevent infection and to maintain hydration and nutrition. Riding a bicycle is not recommended for a child with leukemia because of the risk of falls and injuries, and the measles, mumps, and rubella vaccine is contraindicated for children with leukemia who are receiving chemotherapy. Measuring the temperature orally or axillary is a safe and accurate method for monitoring the child's temperature.
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