Nokea
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.
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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.
When making a distinction as to whether a patient is experiencing confusion related to depression or dementia, what information would be most important for the nurse to consider?
- A. The patient with dementia is persistently angry and hostile.
- B. Early morning agitation and hyperactivity occur in dementia.
- C. Confusion seems to worsen at night when dementia is present.
- D. A patient who is depressed is preoccupied with somatic symptoms.
Correct Answer: C
Rationale: Noting whether the confusion seems to increase at night, which occurs more often with dementia than with depression, will help distinguish the cause of the confused behavior.
Which statement about aging provides the best rationale for focused assessment of older adult patients?
- A. Older adults are often socially isolated and lonely.
- B. As people age, they become more rigid in their thinking.
- C. The majority of older adults sleep more than 12 hours per day.
- D. The senses of vision, hearing, touch, taste, and smell decline with age.
Correct Answer: D
Rationale: Only the correct answer is true and cues the nurse to assess carefully the sensory functions of the older adult patient. The incorrect options are myths about aging.
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.
What is the highest priority for assessment by nurses caring for older adults who self-administer medications?
- A. Use of multiple drugs with anticholinergic effects
- B. Overuse of medications for erectile dysfunction
- C. Misuse of antihypertensive medications
- D. Trading medications with others
Correct Answer: A
Rationale: Anticholinergic effects are cumulative in older adults and often have adverse consequences related to accidents and injuries.