Nokea
A nurse assesses an elderly patient. The nurse should complete the Geriatric Depression Scale if the patient answers which question affirmatively.
- 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: The correct answer is A because assessing the patient's mood is crucial in detecting depression in the elderly. Depression is common in older adults and can often go undiagnosed. By asking about their mood, the nurse can identify potential signs of depression early on. Choices B, C, and D are incorrect as they do not directly relate to assessing depression. Memory issues (B) may indicate cognitive decline, increased alcohol use (C) could suggest substance abuse, and pain (D) may signal physical health concerns, but they are not specific indicators of depression in the elderly.
You may also like to solve these questions
A client with catatonic schizophrenia has been posturing, standing with his left arm upraised and his right foot off the floor. For the most part, he ignores attempts at nursing intervention but will occasionally walk, sit, or lie down for a few minutes. The client eats standing up if the nurse brings a tray to the room. The priority nursing order would be to:
- A. Insist that client sit or lie down for 30 minutes hourly
- B. Assess for lower extremity edema bid
- C. Provide high-calorie drinks hourly
- D. Take client to activities therapy once daily
Correct Answer: B
Rationale: The correct answer is B. Assess for lower extremity edema bid.
Rationale:
1. Priority is to assess for lower extremity edema as the client is standing for extended periods, which can lead to edema.
2. Edema assessment is crucial for preventing complications like blood clots or skin breakdown.
3. Insisting on sitting or lying down may aggravate the client and worsen the situation.
4. Providing high-calorie drinks or activities therapy are not the immediate priority in this case.
In summary, assessing for lower extremity edema is crucial due to the client's prolonged standing, which can lead to potential health risks, making it the priority nursing order.
Which nursing diagnosis would be appropriate for a patient with Alzheimer disease?
- A. Disorientation related to hyperthermia
- B. Anxiety (moderate) related to dementia
- C. Disturbed sensory perception (visual) related to alcohol abuse
- D. Disturbed thought processes related to irreversible brain disorder
Correct Answer: D
Rationale: The correct answer is D: Disturbed thought processes related to irreversible brain disorder. This nursing diagnosis is appropriate for a patient with Alzheimer's disease because Alzheimer's is characterized by cognitive decline and disturbances in thought processes due to irreversible brain changes. Disorientation related to hyperthermia (A) is not directly associated with Alzheimer's. Anxiety related to dementia (B) is a symptom of Alzheimer's, not a nursing diagnosis. Disturbed sensory perception related to alcohol abuse (C) is not relevant to a patient with Alzheimer's disease. It is crucial to focus on the specific symptoms and characteristics of Alzheimer's disease when selecting the appropriate nursing diagnosis.
The first step in the treatment of sleep disorders is to:
- A. Teach prevention.
- B. Give hypnotics for sleep.
- C. Evaluate sleeping patterns.
- D. None of the above.
Correct Answer: C
Rationale: The correct answer is C: Evaluate sleeping patterns. This is the first step in treating sleep disorders because it helps identify the underlying causes and specific nature of the disorder. By understanding the patterns, triggers, and behaviors related to sleep, healthcare providers can tailor effective treatment plans. Choice A (Teach prevention) is incorrect as evaluation comes before prevention strategies. Choice B (Give hypnotics for sleep) is incorrect as medication should be considered only after thorough evaluation. Choice D (None of the above) is incorrect as evaluating sleeping patterns is crucial for effective treatment.
For those family members who desire to care at home for loved ones who have been given a diagnosis of Alzheimer's disease, it is important for the nurse to ensure that the family is aware of which caregiver skills and responsibilities will be necessary. What is one of the responsibilities of the caregiver during the middle stage of the disease?
- A. Helping the loved one with memory and communication problems.
- B. Providing a stable, routine environment.
- C. Providing complete assistance with physical care.
- D. None of the above.
Correct Answer: A
Rationale: Rationale:
1. During the middle stage of Alzheimer's disease, individuals often experience memory and communication problems.
2. Caregivers need to assist with memory tasks and facilitate effective communication.
3. Helping the loved one with memory and communication problems is crucial for their well-being and quality of life.
4. This responsibility helps maintain a sense of connection and understanding between the caregiver and the individual with Alzheimer's.
Summary:
- Option A is correct as it aligns with the specific needs of individuals in the middle stage of Alzheimer's.
- Option B is incorrect as providing a stable, routine environment is more relevant in the early stages.
- Option C is incorrect as complete assistance with physical care is more common in the later stages.
- Option D is incorrect as caregiver responsibilities are essential in all stages of the disease.
The nurse has been working with a patient diagnosed with schizophrenia who experiences auditory hallucinations. The patient relates, 'When I first heard the voices they said nice things about me. Lately, they've changed and they say bad things.' What information has the least impact on therapeutic patient care at this point in the hospitalization?
- A. Do you trust me to help you with the voices?'
- B. Are the voices commanding you to do something?'
- C. How often during 24 hours do you hear the voices?'
- D. Do you hear the voices if you're busy in noisy environment?'
Correct Answer: A
Rationale: Correct Answer: A
Rationale:
A: Asking about trust in the nurse is not immediately relevant as the patient's primary concern is the change in voice content. Building trust is important but addressing the content of hallucinations takes priority.
B: This is relevant as commanding voices could pose a safety risk.
C: Monitoring frequency helps assess severity and response to treatment.
D: Understanding triggers for hallucinations is important for managing symptoms.