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 C

Explanation

A. Plan for your son to meet his sister for the first time at home. This is incorrect because allowing the sibling to visit the newborn in the hospital can help with early bonding and ease the transition.
B. Give your son plenty of "alone time" with his sister. This is incorrect because young children require supervision around infants to ensure safety.
C. Give your son a little gift from his new sister. This is correct because presenting a small gift from the baby helps the older sibling feel included and fosters a positive association with the new arrival.
D. Hold your daughter when your son first meets her. This is incorrect because allowing the older sibling to greet the parent first before introducing the baby can help them feel reassured and less displaced.

A. A client who is at 34 weeks of getation and reports double vision B. A client who is at 38 weeks of gestation and reports leg cramps C. A client who is at 8 weeks of gestation and reports excessive salivation D. A client who is at 24 weeks of gestation and reports periodic finger numbness

Correct Answer is A

Explanation

A. Double vision at 34 weeks of gestation is a potential sign of preeclampsia, which can lead to severe complications such as seizures (eclampsia), stroke, or organ damage. This client requires immediate assessment.
B. Leg cramps are common in late pregnancy due to pressure on nerves and changes in circulation. This is not an urgent concern.
C. Excessive salivation (ptyalism) is benign and can occur in early pregnancy due to hormonal changes. It does not require immediate assessment.
D. Periodic finger numbness is often due to carpal tunnel syndrome, a common non-urgent condition in pregnancy caused by fluid retention.

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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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Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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