Question

A nurse in a community health clinic is assessing a client who has 2 preschoolers, was recently divorced, and is seeking help for managing depression. Which of the following statements should the nurse ask first?

Answer 1

Correct Answers:

Are you having any thoughts of hurting yourself

Rationale :

🔷 The first priority in mental health assessments is to evaluate for risk of self-harm or suicide, which is a safety concern.

🔷 This approach aligns with the principle of Maslow’s hierarchy, where safety is a fundamental priority.

🔷 Asking directly about suicidal ideation is a therapeutic and evidence-based intervention to ensure immediate support.

🔷 Identifying thoughts of self-harm helps the nurse implement crisis prevention measures and referrals promptly

Distractor Analysis :

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Answer 2

Correct Answers:

Describe how you hope the treatments will affect your health

Rationale :

🔶 This response uses cultural humility and promotes open, respectful communication about the client’s health beliefs.

🔶 It reflects culturally competent care by valuing the client’s practices rather than confronting or dismissing them.

🔶 Engaging the client in conversation encourages trust and collaboration, essential in community settings.

🔶 This approach allows the nurse to assess potential benefits or risks while maintaining therapeutic rapport.

Distractor Analysis :

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Answer 3

Correct Answers:

Provide client information on self-help groups for alcohol use disorder

Rationale :

✳️ The first action in discharge planning should address the cause of hospitalization, in this case, alcohol use.

✳️ Referral to self-help groups provides social support and promotes sobriety, which is vital for managing liver disease.

✳️ It is a client-centered and timely intervention that can be initiated immediately.

✳️ This supports long-term recovery and reduces the risk of readmission for complications.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 4

Correct Answers:

Provide client information on self-help groups for alcohol use disorder

Rationale :

♦️ Addressing the client’s alcohol use disorder is crucial before focusing on logistical or physical needs.

♦️ Teaching about self-help groups empowers the client to engage in their recovery and take ownership of sobriety.

♦️ It aligns with the primary goal of discharge planning: preventing relapse and promoting wellness.

♦️ Early referral can also improve long-term compliance with treatment recommendations for cirrhosis.

Distractor Analysis :

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Answer 5

Correct Answers:

Lobbying for funding for health promotion effects
Organizing a program to promote skateboard safety
Teaching a class about the risks of cigarette smoking

Rationale :

💎 Lobbying for funding for health promotion efforts

◾ This is a community-level intervention that supports policy and resource allocation for prevention.

◾ Nurses advocating for funding address system-level determinants of health.

💎 Organizing a program to promote skateboard safety

◾ Promoting injury prevention is a clear example of primary prevention.

◾ It aims to stop accidents before they occur by teaching safety behaviors.

💎Teaching a class about the risks of cigarette smoking

◾ Education to prevent smoking is a classic primary prevention measure.

◾ It reduces risk factors before disease develops, promoting a healthier youth population.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 6

Correct Answers:

I know that everything will be better soon

Rationale :

✴️ This statement reflects hopelessness masked as optimism, a common red flag in clients at risk for suicide.

✴️ Clients with AIDS are at increased risk for depression, especially during the progression of illness and role loss.

✴️ Phrases that sound vague or overly positive can imply imminent plans or resignation.

✴️ Immediate risk assessment and safety planning are warranted to ensure the client’s protection

Distractor Analysis :

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Answer 7

Correct Answers:

Organizing a mass causality drill for community members

Rationale :

🔵 Disaster preparedness involves proactive planning and simulation before an actual emergency occurs.

🔵 Mass casualty drills educate the public and professionals on roles, resources, and responses.

🔵 These activities are essential for evaluating community readiness and identifying gaps in preparedness.

🔵 The nurse plays a key role in promoting community resilience through these structured drills.

Distractor Analysis :

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Answer 8

Correct Answers:

Schedule a vision screening for a client who is experiencing difficulty seeing the whiteboard at school

Rationale :

⚫ Secondary prevention focuses on early detection and prompt intervention for health problems.

⚫ Screening for vision issues allows timely diagnosis and treatment, preventing further complications in learning.

⚫ The school nurse intervenes at the point of early dysfunction, promoting academic and developmental success.

⚫ Secondary interventions are aimed at individuals already showing signs or symptoms.

Distractor Analysis :

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Answer 9

Correct Answers:

Providing parenting classes for local parents

Rationale :

🟢 Primary prevention aims to reduce the incidence of violence by targeting its root causes.

🟢 Parenting classes promote healthy family dynamics, reduce child maltreatment, and strengthen coping strategies.

🟢 These interventions occur before any signs of violence emerge, promoting long-term behavioral change.

🟢 Empowering parents with knowledge and skills enhances the protective environment for children.

Distractor Analysis :

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Answer 10

Correct Answers:

Ask family about the impact of the disease on relationships within the family

Rationale :

🟣 The first step in counseling is to perform a family assessment to understand how the illness affects their dynamics.

🟣 Gathering this insight allows the nurse to tailor education and support services to real family concerns.

🟣 This approach is essential in holistic care, which considers emotional and relational well-being.

🟣 It lays the groundwork for therapeutic communication and promotes family-centered care planning.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

QLexNursing

1 :
A nurse in a community health clinic is assessing a client who has 2 preschoolers, was recently divorced, and is seeking help for managing depression. Which of the following statements should the nurse ask first?

2 :
A nurse at a rural clinic is interviewing a family who has different cultural beliefs than the nurse. The family reports seeing a folk healer. Which of the following statements should the nurse make?

3 :
A case manager is completing discharge planning for a client who has alcohol use disorder andcirrhosis of the liver.Which of the following actions should the case manager take first?

4 :
A case manager is completing discharge planning for a client who has alcohol use disorder and cirrhosis of the liver.Which of the following actions should the case manager take first?

5 :
A school nurse is planning primary prevention activities for the new school year. Which of the following should the nurse include? (SATA)

6 :
A home health nurse is assessing a client who has Al DS. Which of the following responses by the client indicates a risk for suicide?

7 :
A nurse is serving a state task force for disaster planning.The nurse is engaging in disasterpreparedness efforts when performing which of the following actions?

8 :
A nurse manager at a clinic is reviewing the preventive services offered to clients. Which of the following activities the nurse identify as a secondary prevention activity?

9 :
A community nurse health nurse is working with a task force to decrease community violence.Which of the following planned interventions should the nurse identify as a primary prevention strategy?

10 :
A parish nurse is counseling a family following a client's recent dx with heart diseases. Which of the following actions should the nurse take first?

QLexNursing

1 : A nurse in a community health clinic is assessing a client who has 2 preschoolers, was recently divorced, and is seeking help for managing depression. Which of the following statements should the nurse ask first?

2 : A nurse at a rural clinic is interviewing a family who has different cultural beliefs than the nurse. The family reports seeing a folk healer. Which of the following statements should the nurse make?

3 : A case manager is completing discharge planning for a client who has alcohol use disorder andcirrhosis of the liver.Which of the following actions should the case manager take first?

4 : A case manager is completing discharge planning for a client who has alcohol use disorder and cirrhosis of the liver.Which of the following actions should the case manager take first?

5 : A school nurse is planning primary prevention activities for the new school year. Which of the following should the nurse include? (SATA)

6 : A home health nurse is assessing a client who has Al DS. Which of the following responses by the client indicates a risk for suicide?

7 : A nurse is serving a state task force for disaster planning.The nurse is engaging in disasterpreparedness efforts when performing which of the following actions?

8 : A nurse manager at a clinic is reviewing the preventive services offered to clients. Which of the following activities the nurse identify as a secondary prevention activity?

9 : A community nurse health nurse is working with a task force to decrease community violence.Which of the following planned interventions should the nurse identify as a primary prevention strategy?

10 : A parish nurse is counseling a family following a client's recent dx with heart diseases. Which of the following actions should the nurse take first?

1 :
A nurse in a community health clinic is assessing a client who has 2 preschoolers, was recently divorced, and is seeking help for managing depression. Which of the following statements should the nurse ask first?

2 :
A nurse at a rural clinic is interviewing a family who has different cultural beliefs than the nurse. The family reports seeing a folk healer. Which of the following statements should the nurse make?

3 :
A case manager is completing discharge planning for a client who has alcohol use disorder andcirrhosis of the liver.Which of the following actions should the case manager take first?

4 :
A case manager is completing discharge planning for a client who has alcohol use disorder and cirrhosis of the liver.Which of the following actions should the case manager take first?

5 :
A school nurse is planning primary prevention activities for the new school year. Which of the following should the nurse include? (SATA)

6 :
A home health nurse is assessing a client who has Al DS. Which of the following responses by the client indicates a risk for suicide?

7 :
A nurse is serving a state task force for disaster planning.The nurse is engaging in disasterpreparedness efforts when performing which of the following actions?

8 :
A nurse manager at a clinic is reviewing the preventive services offered to clients. Which of the following activities the nurse identify as a secondary prevention activity?

9 :
A community nurse health nurse is working with a task force to decrease community violence.Which of the following planned interventions should the nurse identify as a primary prevention strategy?

10 :
A parish nurse is counseling a family following a client's recent dx with heart diseases. Which of the following actions should the nurse take first?