A nurse in a community health clinic is conducting an assessment of a client who has two preschool-aged children, has recently gone through a divorce, and is seeking help for managing depression.
Which of the following
Questions should the nurse ask first?
“Could you describe how you are feeling today?”
“Are you having any thoughts about hurting yourself?”
“Is there anything that makes you feel less depressed?”
“Who is available to help you?”
The Correct Answer is B
Choice A rationale
Asking the client to describe how they are feeling today is an important part of the assessment. However, when dealing with a client who is managing depression, the nurse’s first priority should be to ensure the safety of the client.
Choice B rationale
Asking if the client is having any thoughts about hurting themselves is the first question the nurse should ask. This is because safety is always the top priority, and clients dealing with depression may be at risk for self-harm or suicide.
Choice C rationale
While it’s important to understand what makes the client feel less depressed, this question is not as immediately critical as assessing for potential self-harm or suicide risk.
Choice D rationale
Understanding the client’s support system is an important part of the assessment, but it is not the first priority. The nurse’s initial focus should be on assessing the client’s immediate safety and mental health status.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Evaluating the effectiveness of local disaster-preparedness drills is an important step in disaster management. However, it is not the first action to take when developing a disaster- preparedness plan. This step usually comes later, after identifying the community’s risks and capabilities, assembling a team, and providing education.
Choice B rationale
Assembling an emergency disaster response team is crucial in disaster management. However, before assembling a team, it is important to first identify the community’s risks and capabilities. This will help in determining the composition and roles of the team members.
Choice C rationale
Providing education about first aid and triage is an essential part of disaster preparedness. However, this is not the first step. Before providing education, it is important to first understand the community’s risks and capabilities.
Choice D rationale
Identifying the community’s risks and capabilities is the first action to take when developing a disaster-preparedness plan. This involves determining what natural disasters the community is likely to face and the community’s capacity to respond to these disasters.
Correct Answer is A
Explanation
Choice A rationale
This is the correct answer. Regular eye examinations are important for early detection of eye diseases and conditions. The American Optometric Association recommends adults aged 18 to 60 have an eye exam at least every two years, and adults 61 and older have an eye exam annually.
Choice B rationale
Regular monitoring of blood glucose levels is crucial for individuals with diabetes or those at risk. However, the frequency of checking fasting blood glucose levels can vary depending on individual health status and risk factors.
Choice C rationale
Stool tests for blood are used to detect colorectal cancer. The American Cancer Society recommends that adults aged 45 and older with an average risk of colorectal cancer undergo regular screening with either a high-sensitivity stool-based test or a structural (visual) exam, depending on the patient’s preference and test availability.
Choice D rationale
Regular hearing screenings are important, especially as individuals age. However, the frequency of hearing screenings can vary based on individual risk factors and symptoms.
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