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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Reviewing the immunization records of the child’s classmates might be a subsequent step after confirming the diagnosis and reporting to the health department. However, the immediate action should be to contact the local health department.
Choice B rationale
Advising the caregivers to increase the child’s Vitamin B intake is not relevant in this context. Koplik spots are a sign of measles, a viral infection, and increasing Vitamin B intake would not affect the course of this disease.
Choice C rationale
Examining the child’s classmates for enlargement of the parotid gland is not appropriate because enlargement of the parotid gland is a symptom of mumps, not measles.
Choice D rationale
Contacting the local health department is the correct action. Koplik spots are a characteristic sign of measles, a highly contagious and reportable disease. The local health department can provide guidance on further steps, including confirmation of the diagnosis, treatment, and measures to prevent the spread of the disease.
Correct Answer is A
Explanation
Choice A rationale
The first action to take in the initial phase of planning a smoking cessation program should be to determine the prevalence of smoking in the community. This is important because it helps to understand the magnitude of the problem and the potential impact of the program. It also helps in setting realistic goals for the program and in securing funding and other resources.
Choice B rationale
While formulating objectives for the smoking cessation program is an important step, it should come after determining the prevalence of smoking in the community. The objectives should be based on the needs and characteristics of the target population, which can only be understood by first assessing the prevalence.
Choice C rationale
Gaining community support for the program is crucial for its success. However, this should come after the prevalence of smoking has been determined and objectives for the program have been formulated.
Choice D rationale
Evaluating the methods of successful smoking cessation programs can provide valuable insights for planning the program. However, this should not be the first action. The first step should be to understand the extent of the problem in the community.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.