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A 75-year-old patient comes to the clinic reporting frequent headaches. After an introduction at the beginning of the interview, what should the nurse address?
- A. Initiate a neurological assessment.
- B. Assess if the patient can hear the spoken word clearly.
- C. Suggest that the patient lie down in a darkened room to rest.
- D. Administer medication to relieve the patient's pain prior to the assessment.
Correct Answer: B
Rationale: Before proceeding, the nurse should assess the patient's ability to hear questions. Hearing ability often declines with age. Impaired hearing could lead to inaccurate answers.
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A patient tells the nurse of the recent deaths of a spouse of 50 years as well as an adult child in an automobile accident. The patient has no other family and only a few friends in the community. What is the priority nursing diagnosis?
- A. Spiritual distress, related to being angry with God for taking the family
- B. Risk for suicide, related to recent deaths of significant others
- C. Anxiety, related to sudden and abrupt lifestyle changes
- D. Social isolation, related to loss of existing family
Correct Answer: B
Rationale: The patient appears to be experiencing normal grief, but due to age and social isolation, the risk for suicide is a high-priority nursing diagnosis.
A nurse asks the following questions while assessing an older adult. The nurse will add the Geriatric Depression Scale as part of the assessment if the patient answers 'yes' to which question?
- A. Would you say your mood is often sad?'
- B. Are you having any trouble with your memory?'
- C. Have you noticed an increase in your alcohol use?'
- D. Do you often experience moderate-to-severe pain?'
Correct Answer: A
Rationale: Sadness may be a symptom of depression. Sad moods occurring with regularity should signal the need to assess further for other symptoms of depression.
An 80-year-old patient has difficulty walking because of arthritis and says, 'It's awful to be old. Every day is a struggle. No one cares about old people.' Which is the nurse's most therapeutic response?
- A. Everyone here cares about old people. That's why we work here.'
- B. It sounds like you're having a difficult time. Tell me about it.'
- C. Let's not focus on the negative. Tell me something good.'
- D. You are still able to get around, and your mind is alert.'
Correct Answer: B
Rationale: The nurse uses therapeutic communication and empathic understanding to encourage the patient to express frustration and clarify the 'struggle' for the nurse.
An older adult with a history of major depressive disorder has taken an antidepressant daily for 3 years. The patient tells the nurse, 'I want to stop taking this medication. I don't think I need it anymore.' What is the nurse's best response to assure the patient's safety?
- A. Why do you think you don't need this medication anymore?'
- B. Have you talked with your family members about this decision?'
- C. If you stop the medication, your depression will return worse than ever.'
- D. This medication should be gradually stopped. Let's talk to your health care provider about a plan.'
Correct Answer: D
Rationale: A gradual discontinuation is needed to avoid discontinuation symptoms, ensuring patient safety.
A 79-year-old white man tells a visiting nurse, 'I've been feeling sad lately. My family and friends are all dead. My money is running out, and my health is failing.' How should the nurse analyze this comment?
- A. Normal negativity of older adults
- B. Evidence of suicide risk
- C. A cry for sympathy
- D. Normal grieving
Correct Answer: B
Rationale: The patient describes the loss of significant others, economic insecurity, and declining health, which are risk factors for suicide, especially in older adult white men.