If the home health nurse documented all of the following findings, whi

Question 1 of 5.

If the home health nurse documented all of the following findings, which one is most suggestive that the client is depressed?

A. The client is irritable after grandchildren visit.

B. The client has multiple, unrelated physical complaints.

C. The client takes lengthy naps in the late afternoon.

D. The client cries when talking about a dead spouse.

Explanation: Multiple somatic complaints are a hallmark of depression in older adults, often masking emotional symptoms.

Question 2 of 5.

Which response by the nurse is most accurate?

A. It will show up in urine tests 3 to 4 days after use.

B. Traces may be picked up by sensitive blood tests 8 to 10 weeks later.

C. Hair analysis can detect marijuana use more than a year before the urine test.

D. Marijuana leaves the body within 2 hours of smoking it.

Explanation: Marijuana metabolites can be detected in blood tests for weeks, with sensitive tests picking up traces 8 to 10 weeks after use, depending on frequency and amount used.

Question 3 of 5.

When the nurse responds to a call from a 22-year-old rape victim, which instruction is most important before referring the client to the emergency department of the local hospital?

A. Do not bathe or shower.

B. Make a sketch of the rapist.

C. Write down what happened.

D. Call a 911 operator.

Explanation: Advising the victim not to bathe preserves forensic evidence, which is critical for potential criminal investigation and prosecution.

Question 4 of 5.

Which action by the client is most suggestive of denial about the illness?

A. The client conceals the information from family members.

B. The client avoids contact with homosexual friends.

C. The client responds to the former group of the nurse.

D. The client has intercourse without using condoms.

Explanation: Engaging in unprotected intercourse indicates denial of the HIV diagnosis, as it disregards the risk of transmission and personal health implications.

Question 5 of 5.

Which finding in the client's history strongly suggests lack of achieving the characteristic developmental level expected at this age in the life cycle?

A. The client drifts in and out of relationships.

B. The client worries about financial security.

C. The client questions personal sexual identity.

D. The client hesitates to be assertive.

Explanation: Drifting in and out of relationships indicates difficulty achieving intimacy, a key developmental task of young adulthood per Erikson's stages.