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 B

Explanation

A. A bologna sandwich on rye bread: Rye bread contains gluten, which is harmful to individuals with celiac disease. Therefore, foods containing gluten, such as rye bread, should be avoided in the diet of a preschooler with celiac disease.
B. Corn tortilla with black beans: Corn tortillas and black beans are both gluten-free options and suitable for individuals with celiac disease. Corn tortillas are made from cornmeal, which does not contain gluten, making them a safe choice for individuals with celiac disease. Black beans are also naturally gluten-free and can provide essential nutrients like protein and fiber to the preschooler's diet.
C. Whole wheat pasta with shrimp: Whole wheat pasta contains gluten, which is not suitable for individuals with celiac disease. Therefore, whole wheat pasta should be avoided in the diet of a preschooler with celiac disease.
D. Low sodium vegetable soup with barley: Barley contains gluten and is not suitable for individuals with celiac disease. Therefore, foods containing barley, such as vegetable soup with barley, should be avoided in the diet of a preschooler with celiac disease.

A. Instruct a client on the use of an incentive spirometer. B. Insert an NG tube for a client who requires enteral feedings. C. Obtain a client's vital signs every 4 hr. D. Record a client's intake after each meal, E. Transfer a client to physical therapy.

Correct Answer is ["C","D","E"]

Explanation

C. Obtain a client's vital signs every 4 hr:
This task can typically be delegated to assistive personnel (AP) who have been trained and deemed competent in measuring vital signs. Routine monitoring of vital signs, such as temperature, pulse, respirations, and blood pressure, is within the scope of practice for AP and does not require the specialized skills of a licensed nurse.

D. Record a client's intake after each meal:
Assistive personnel can be delegated the task of recording a client's intake after each meal. This involves documenting the amount and type of food and fluids consumed by the client. While assessment of intake may involve some judgment, AP can be trained to perform this task accurately and consistently.

E. Transfer a client to physical therapy:
Assistive personnel can assist with transferring clients to physical therapy sessions. This may include tasks such as assisting clients into a wheelchair or onto a stretcher and accompanying them to the therapy area. While ensuring client safety during transfers is crucial, AP can perform these tasks under the direction and supervision of licensed nursing staff or physical therapists.

A. Instruct a client on the use of an incentive spirometer:
Teaching clients how to use medical equipment, such as an incentive spirometer, typically requires specialized knowledge and skills that fall within the scope of practice of licensed nursing staff. Therefore, this task should not be delegated to assistive personnel.

B. Insert an NG tube for a client who requires enteral feedings:
Inserting an NG tube is a specialized nursing skill that requires training, expertise, and an understanding of anatomy, proper technique, and potential complications. This task should only be performed by licensed nursing staff, such as registered nurses (RNs) or licensed practical nurses (LPNs), who have received appropriate education and training.

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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 providing dietary teaching to the guardian of a preschooler who has celiac disease. Which of the following foods should the nurse recommend including in the preschooler's diet?

Correct Answer is B

Explanation

A nurse is planning assignments for the upcoming shift. Which of the following tasks should the nurse delegate to an assistive personnel? (Select all that apply.)

Correct Answer is ["C","D","E"]

Explanation

A nurse is caring for a client who is preoperative for cataract removal. Which of the following statements by the client indicates an understanding of the procedure?

A nurse is providing discharge teaching to a client who has GERD. Which of the following information should the nurse include?

A nurse is caring for a client who has a peritoneal catheter that requires a dressing change. Identify the sequence of actions the nurse should take. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

A nurse is teaching a client who has major depressive disorder about what to expect when undergoing electroconvulsive therapy. Which of the following information should the nurse give the client?

A nurse is teaching a client who is pregnant about nonstress testing. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is teaching a client how to care for their behind-the-ear hearing aids. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is caring for a preschooler who is in an acute care facility. Which of the following actions should the nurse take?

A nurse is creating an incident report due to an accidental omission of a client's dressing change during the previous shift. Which of the following statements should the nurse document on the incident report form?