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?"

"Do you ever think about harming yourself?"

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

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

Answer and Explanation

The Correct Answer is B

A. "Did anything in particular make you feel this way?" - While exploring potential triggers for the client's feelings of uselessness is important, assessing for suicidal ideation takes precedence. However, this question can be asked after addressing the immediate safety concern.
B. "Do you ever think about harming yourself?" - This is the priority assessment question. Older adults experiencing feelings of uselessness and worthlessness may be at risk for suicidal ideation or self-harm. Asking about thoughts of self-harm allows the nurse to assess the client's safety and determine the need for immediate intervention.
C. "How long have you had these feelings of uselessness?" - While understanding the duration of the client's feelings is relevant, assessing for suicidal ideation is more critical in ensuring the client's safety.
D. "Would you tell me more about the changes you see in your body?" - Exploring the client's perception of physical changes is important for addressing body image concerns and promoting self-esteem. However, assessing for suicidal ideation takes precedence as it addresses the client's immediate safety.

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Correct Answer is D

Explanation

A. Contact precautions are used for infections transmitted by direct or indirect contact with the client or their environment. Examples include MRSA, C. difficile, and other multidrug-resistant organisms.
B. Airborne precautions are used for infections transmitted by small droplets that remain suspended in the air and can be inhaled. Examples include tuberculosis (TB), measles, and chickenpox (varicella).
C. Protective environment precautions are typically used for clients with compromised immune systems, such as those undergoing stem cell transplants, to protect them from environmental pathogens.
D. Droplet precautions are used for infections transmitted by large respiratory droplets that can travel up to approximately 3 feet. Examples include bacterial meningitis, influenza, and pertussis. Therefore, the nurse should initiate droplet precautions for the school-age child with bacterial meningitis.

A. Request insertion of a tracheostomy tube. B. Suction the client's airway. C. Tighten the tubing connections. D. Look for a leak in the tube's cuff.

Correct Answer is B

Explanation

Answer: B

Rationale:

A) Request insertion of a tracheostomy tube: The high-pressure alarm on a ventilator typically indicates increased resistance to airflow within the airway, which may be due to secretions, bronchospasm, or another obstruction. Requesting insertion of a tracheostomy tube is not the first action the nurse should take in response to a high-pressure alarm. Instead, the nurse should assess and manage potential causes of increased airway resistance before considering a change in airway management.

B) Suction the client's airway: Suctioning the client's airway is the priority action in response to a high-pressure alarm on the ventilator. Increased airway pressure may be due to secretions or a mucus plug, leading to airway obstruction. Suctioning helps clear the airway and restore effective ventilation.

C) Tighten the tubing connections: While loose tubing connections can contribute to air leaks and decreased ventilation efficiency, they are not the primary cause of a high-pressure alarm. Tightening tubing connections may be necessary but is not the initial action in response to a high-pressure alarm.

D) Look for a leak in the tube's cuff: Checking for a leak in the endotracheal tube cuff is essential to ensure an adequate seal and prevent aspiration. However, it is not the first action the nurse should take in response to a high-pressure alarm. The priority is to address potential airway obstruction by suctioning the client's airway to remove secretions or other obstructions.

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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 is admitting a school-age child who has bacterial meningitis. Which of the following types of isolation precautions should the nurse initiate?

Correct Answer is D

Explanation

While a nurse is caring for a client who is receiving mechanical ventilation via an endotracheal tube, the high-pressure alarm on the ventilator sounds. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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