A nurse in a provider's office is talking with an older adult client who tells the nurse that they fear they are "aging badly" and feel "so useless." Which of the following assessment questions is the nurse's priority?

"Did anything in particular make you feel this way?"

"Would you tell me more about the changes you see in your body?"

"Do you ever think about harming yourself?"

"How long have you had these feelings of uselessness?"

Answer and Explanation

The Correct Answer is C

A. "Did anything in particular make you feel this way?" Understanding the cause of the client’s feelings is important, but assessing for immediate safety takes priority.
B. "Would you tell me more about the changes you see in your body?" Exploring the client’s perception of aging is useful, but it does not address potential risk for self-harm.
C. "Do you ever think about harming yourself?" This is the priority assessment question because feelings of worthlessness can indicate depression, which increases the risk of suicide in older adults. Assessing for self-harm ensures immediate safety.
D. "How long have you had these feelings of uselessness?" Identifying the duration of these feelings is relevant, but it is secondary to determining whether the client is at risk for self-harm.

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Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"B"}}

Explanation

Findings Consistent with Chorioamnionitis:

Purulent amniotic fluid
Fever

Findings Consistent with Preeclampsia:

Elevated uric acid level
Decreased platelet count
Blurred vision

Rationale:

Purulent amniotic fluid (Chorioamnionitis): Chorioamnionitis is an intra-amniotic infection, often leading to foul-smelling, purulent, or discolored amniotic fluid.
Fever (Chorioamnionitis): Maternal fever is a hallmark sign of chorioamnionitis, indicating infection.
Elevated uric acid level (Preeclampsia): Uric acid elevation is associated with endothelial dysfunction and reduced renal clearance seen in preeclampsia.
Decreased platelet count (Preeclampsia): Thrombocytopenia can occur due to platelet consumption in severe preeclampsia or HELLP syndrome.
Blurred vision (Preeclampsia): Visual disturbances occur due to cerebral edema and vasospasms, common in preeclampsia.

A. A client who had dialysis and is using an arteriovenous shunt in the left lower forearm B. A client who had a right hemisphere stroke C. A client who has a right peripherally inserted central catheter D. A client who had blood drawn from the right antecubital area 1 hr ago

Correct Answer is C

Explanation

A. A client who had dialysis and is using an arteriovenous shunt in the left lower forearm. This is incorrect because the arteriovenous shunt is in the lower forearm, not the upper arm where blood pressure is measured. The right arm can still be used.
B. A client who had a right hemisphere stroke. This is incorrect because a stroke does not necessarily contraindicate blood pressure measurement on the affected side unless there are complications such as edema or weakness.
C. A client who has a right peripherally inserted central catheter. This is correct because taking a blood pressure on the same side as a peripherally inserted central catheter (PICC) can cause pressure that may damage the catheter or affect its function. The left arm should be used instead.
D. A client who had blood drawn from the right antecubital area 1 hr ago. This is incorrect because drawing blood from an arm does not contraindicate blood pressure measurement in that arm after a short period.

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A nurse in a provider's office is talking with an older adult client who tells the nurse that they fear they are "aging badly" and feel "so useless." Which of the following assessment questions is the nurse's priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in an antepartum unit is caring for a client. Exhibits For each potential assessment finding, click to specify if the finding is consistent with chorioamnionitis or preeclampsia. Each finding may support more than one disease process.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"B"}}

Explanation

A nurse is observing an assistive personnel (AP) measure blood pressures from the right arms of a group of clients. The nurse should instruct the AP to measure the blood pressure in the left arm of which of the following clients?

Correct Answer is C

Explanation

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