An older adult client tells the home health practical nurse (PN) of not having any money, and a belief of not deserving to eat, so the client has not asked anyone to help provide food. Which information is most important for PN to obtain?
Community resources to provide financial aid.
Availability of family members to provide meals.
Medication history for antipsychotic agents.
Client thoughts about wanting to hurt himself.
The Correct Answer is D
A. Community resources to provide financial aid: This is important for long-term support but does not address the urgent need to assess for suicidal intent in a client expressing hopelessness and self-neglect.
B. Availability of family members to provide meals: Relevant for nutritional support planning, but not the priority when the client has expressed feelings of worthlessness.
C. Medication history for antipsychotic agents: Could identify causes of decreased appetite or mood, but it is not the first priority.
D. Client thoughts about wanting to hurt himself: Expressions of not deserving to eat and hopelessness may indicate suicidal ideation; assessing for self-harm risk takes priority for client safety.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Recommend analgesic perineal spray: Helps pain but not top priority for preventing complications.
B. Administer stool softener: Prevents strain that could disrupt complex repair.
C. Give PRN sleep medication: Comfort measure but low priority.
D. Encourage breastfeeding: Helps uterine involution but unrelated to laceration healing.
Correct Answer is B
Explanation
A. Withhold the medication and notify the charge nurse: Not needed; goiter is common in hypothyroidism, and there are no swallowing/breathing issues.
B. Administer the oral medication with a glass of water as scheduled: No contraindication; continue therapy as prescribed.
C. Place the client on NPO status: Not indicated unless airway compromise or swallowing difficulty is present.
D. Crush the medication and mix with applesauce: Levothyroxine should be taken whole with water on an empty stomach for optimal absorption.
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