An older female client tells the home health nurse that she has no money, and since she does not deserve to eat, she has not asked anyone to bring her food. Which information is most important for the nurse to obtain?
Medication history for antipsychotic agents.
Availability of family members to provide meals.
Client thoughts about wanting to hurt herself.
Community resources to provide financial aid.
The Correct Answer is C
Choice A reason: While medication history is important for understanding psychiatric background, it does not address the immediate concern of potential self-harm or suicidal ideation. Antipsychotic use may suggest mental health issues, but the priority is assessing current risk.
Choice B reason: Knowing whether family members can provide meals is relevant for addressing food insecurity, but it does not address the deeper psychological concern expressed by the client. The statement about not deserving to eat suggests emotional distress that may precede self-harm.
Choice C reason: The client’s statement reflects possible suicidal ideation or severe depression. Assessing thoughts of self-harm is the highest priority to ensure safety and initiate appropriate mental health interventions. This aligns with the nursing process of prioritizing physiological and psychological safety.
Choice D reason: Financial aid resources may help with food access, but they are secondary to evaluating the client’s mental health status. Without addressing emotional well-being, resource referrals may be ineffective or ignored.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Employee turnover affects staffing stability but does not directly reflect client outcomes. It is more relevant to administrative and human resource evaluations.
Choice B reason: The rate of client death may be influenced by the population’s age and health status, making it a less reliable indicator of care quality unless deaths are unexpected or preventable.
Choice C reason: Falls are a key quality indicator in long-term care settings. They reflect safety, supervision, and effectiveness of fall prevention strategies. Tracking fall rates helps identify areas for improvement and aligns with national patient safety goals.
Choice D reason: Employee satisfaction is important for retention and morale but does not directly measure client outcomes. It is a secondary metric in evaluating care standards.
Correct Answer is B
Explanation
Choice A reason: A medication history is useful but not the first priority. It helps identify overuse or contraindications, but understanding the cause of the headache is more immediately relevant to safe and effective care.
Choice B reason: Identifying potential triggers such as stress, dehydration, lack of sleep, or screen time helps guide appropriate intervention. This assessment ensures that treatment addresses the underlying issue rather than masking symptoms.
Choice C reason: Reviewing absenteeism may provide context for chronic issues but does not help manage the current complaint. It is more relevant for long-term follow-up.
Choice D reason: Offering a snack and water may relieve symptoms if the headache is due to hunger or dehydration, but it should follow an assessment of possible causes to avoid overlooking serious conditions.
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