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 B

Explanation

A. Obtain a tympanogram reading prior to initiating the test. This is incorrect because a tympanogram assesses middle ear function and is not part of the Weber test, which evaluates hearing loss type.
B. Place a vibrating tuning fork on the top of the child's head. This is correct because the Weber test involves placing a vibrating tuning fork on the midline of the skull to determine if sound is heard equally in both ears, helping to differentiate between conductive and sensorineural hearing loss.
C. Hold a vibrating tuning fork 1 to 2 cm (0.4 to 0.8 in) from the child's ears. This is incorrect because this describes the Rinne test, which compares air conduction to bone conduction.
D. Measure the amount of time the child can hear the sound. This is incorrect because the Weber test does not measure duration but assesses lateralization of sound perception.

A. Schedule the client for an MRI after the procedure. B. Place the client leaning forward over the overbed table. C. Encourage the client to take deep breaths during the procedure. D. Ensure the client has been NPO for 6 hr.

Correct Answer is B

Explanation

A. Schedule the client for an MRI after the procedure. This is incorrect because an MRI is not required following a thoracentesis. Instead, a chest X-ray may be ordered to assess for complications such as a pneumothorax.
B. Place the client leaning forward over the overbed table. This is correct because this position allows for optimal lung expansion and easier access to the pleural space for fluid removal.
C. Encourage the client to take deep breaths during the procedure. This is incorrect because the client should remain still and avoid deep breathing or coughing to prevent lung injury.
D. Ensure the client has been NPO for 6 hr. This is incorrect because NPO status is not required for a thoracentesis, as it is not a gastrointestinal or sedation-based procedure.

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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

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