A nurse is collecting data from a client who is expressing suicidal ideations. Which of the following questions is the nurse's priority?

"Can you tell me about the stresses in your life?"

"Has anyone in your family ever died by suicide?

“Do you have a plan for harming yourself?"

“Do you have someone to discuss your feelings with?"

Answer and Explanation

The Correct Answer is C

Assessing the client's suicidal intent and the presence of a specific plan for self-harm is crucial in determining the level of immediate risk and the need for intervention. This question directly addresses the client's current state and potential danger.

While all the questions are important in assessing the client's situation, determining the presence of a plan for self-harm takes precedence as it helps evaluate the level of imminent danger and the need for immediate intervention.

The other questions are also important but can be addressed after ensuring the client's safety and appropriate intervention based on the information gathered regarding the plan for self-harm. These questions can provide additional information to further assess the client's support system, history, and current stressors, which can contribute to understanding the context and potential risk factors for the client.

Remember, if the client expresses an immediate plan and intent for self-harm, it is essential to take appropriate steps to ensure their safety, such as involving the appropriate mental health professionals, implementing a safety plan, and providing constant supervision as needed.

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Correct Answer is C

Explanation

explanation:

Adult day care facilities provide a safe and supervised environment for older adults during the day, while their family members or caregivers are at work or unable to be present. These facilities offer various activities, social interactions, and personal care services to support the needs of individuals with dementia and other conditions. Attending an adult day care facility canalso give the client an opportunity to engage with others and maintain cognitive and physical stimulation.

A- Hospice care is generally recommended for individuals with terminal illnesses who are nearing the end of life. It focuses on providing comfort and support to the patient and family during the end-of-life journey.

B- Long-term care facilities may be appropriate for some individuals with advanced dementia who require round-the-clock care and supervision. However, in this scenario, the client's adult child is present and working full time, suggesting that the family intends to provide care at home as much as possible.

D- Community senior centers may offer various activities and programs for older adults, but they may not provide the level of supervision and care required for an individual with early onset dementia during the day, especially if their family member is at work.

A. Apply suction while inserting the catheter. B. Apply intermittent suction for 15 seconds. C. Wait 1 min between suctioning attempts. D. Insert the catheter 10 cm (4 in).

Correct Answer is C

Explanation

A.This is incorrect because suction should not be applied during the insertion of the catheter. Suctioning should only be applied while withdrawing the catheter to avoid causing trauma to the mucosa.

B. Suctioning should generally be performed for no longer than 10 seconds at a time to minimize the risk of complications such as hypoxia.

C.This response is correct because waiting approximately 1 minute between suctioning attempts allows the client time to recover and reoxygenate. This interval helps prevent hypoxia and mucosal damage, which are important considerations during the suctioning process.

D.In adults insert catheter approximately 16 cm (6.5 inches); in older children, 8– 12 cm (3–5 inches); in infants and young children, 4–7.5 cm (1.5–3 inches). Rule of thumb is to insert catheter distance from tip of nose (or mouth) to angle of mandible.

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A nurse is collecting data from a client who is expressing suicidal ideations. Which of the following questions is the nurse's priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the discharge of an older adult client who has early onset dementiaand lives with their adult child who works full time Which of the following resources should thenurse recommend to the family to assist with the client's care?

Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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