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
In the epidemiological triangle, the virus is considered the agent, not the host.
Choice B rationale
The vaccine is a form of intervention to prevent the disease, not the host.
Choice C rationale
The school could be considered the environment in which the host (the children) and the agent (the virus) interact, but it is not the host itself.
Choice D rationale
This is the correct answer. In the context of a mumps outbreak among school-age children, the children are the hosts. They are the ones who can become infected with the mumps virus.
Correct Answer is B
Explanation
Choice A rationale
While it’s important to respect the adolescent’s privacy and avoid causing embarrassment, directing the conversation solely to the parents may not fully address the needs of the adolescent. Adolescents with cancer often have their own questions and concerns, and they should be included in discussions about their care.
Choice B rationale
This is the correct answer. Understanding how the adolescent’s health has affected family roles can help the nurse provide appropriate support and resources. Cancer can significantly impact family dynamics, and addressing these changes is an important part of holistic care.
Choice C rationale
While discussing future career plans can be a part of the conversation, it should not be the primary focus of the meeting. The immediate concern is usually the adolescent’s health and well-being.
Choice D rationale
While support from the faith community can be beneficial, it’s important to respect the family’s privacy. Inviting another family from the same faith congregation to attend the meeting should only be done with the family’s consent.
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