Which question is most important for a nurse to ask an older adult client who has reported increased weakness and new bruises?
"How many stairs do you have in your home?"
"Are you taking any new over-the-counter medications?"
"Do you feel you would benefit from an assistive device in your home?"
"Can you tell me more about your increased weakness and bruises?"
The Correct Answer is D
Choice A reason: Asking about stairs addresses environmental safety but does not directly assess the acute concerns of weakness and bruising.
Choice B reason: While medication use may contribute to bruising or weakness, it is secondary to assessing the presenting symptoms.
Choice C reason: Assessing need for assistive devices is important for fall prevention, but first understanding the cause of weakness and bruises is the priority.
Choice D reason: Asking for more details about the reported weakness and bruises directly addresses the client’s presenting problem, allows for comprehensive assessment, and helps identify potential underlying medical issues such as bleeding disorders, nutritional deficiencies, or abuse.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: A talkative client can be a barrier to effective communication if they dominate the conversation, preventing the nurse from gathering necessary information or addressing key concerns. Communication must be balanced to ensure mutual understanding.
Choice B reason: Maintaining eye contact is a facilitator of effective communication. It conveys attentiveness, respect, and engagement.
Choice C reason: Active listening is a therapeutic communication technique. It ensures the nurse understands the client’s concerns and validates their feelings.
Choice D reason: A cooperative client enhances communication. Cooperation fosters trust and openness, allowing for effective exchange of information.
Correct Answer is C
Explanation
Choice A reason: A history of previous fractures or injuries indicates past vulnerability but does not necessarily predict imminent risk. While it is important to assess for past injuries to provide preventive education, it is not the most immediate or life-threatening risk factor.
Choice B reason: Engagement in unsupervised sports activities can increase risk of minor injuries; however, these are usually less severe and less life-threatening compared to high-risk behaviors such as driving recklessly.
Choice C reason: Risk-taking behaviors while driving are a major cause of morbidity and mortality among adolescents. This behavior poses an immediate and severe risk for injury or death, making it the priority for assessment and intervention.
Choice D reason: Curiosity about sexual activities is a normal part of adolescent development. While it carries potential risks such as sexually transmitted infections or unintended pregnancy, it is less immediately life-threatening compared to high-risk behaviors like unsafe driving.
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