Nokea
A nurse in an assisted-living facility is caring for a client who is in early stages of dementia. The client has been oriented to name and place and is usually cooperative. Which of the following nursing actions is appropriate if the client refuses to take morning medications?
- A. Notify the charge nurse of the need for evaluation of the client's level of competence.
- B. Ask the client to express her reasons for refusing the morning medications and document the event.
- C. Crush the pills, if not contraindicated, and hide them in the client's applesauce.
- D. Try to talk the client into adherence by telling her the possible implications of missing a dose.
Correct Answer: B
Rationale: Competence evaluation follows understanding refusal. Asking reasons respects autonomy and informs care. Crushing pills without consent is unethical and risky. Coercion dismisses client rights; understanding is better.
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Which of the following is a physical clinical finding of depression in older adults?
- A. Increased anxiety
- B. Slowed memory
- C. Slowed intellect
- D. Headache
Correct Answer: D
Rationale: Increased anxiety is a psychological symptom, not a physical finding, though it may accompany depression. Slowed memory and intellect are cognitive symptoms related to depression’s impact on thinking, not physical manifestations. Physical symptoms of depression can include changes in sleep, appetite, or pain, such as headaches, which are commonly reported in older adults as a somatic expression of the disorder.
Which of the following mental health disorders commonly occurs in older adults?
- A. Personality disorder
- B. Depression
- C. Somatoform disorder
- D. Schizophrenia
Correct Answer: B
Rationale: Personality disorders are lifelong, not age-specific. Depression is prevalent in older adults due to health and social changes. Somatoform disorders aren’t age-specific. Schizophrenia onset is earlier, not typical in later life.
A hospitalized client sees snakes on the walls of the hospital room and becomes anxious. This is an example of which of the following?
- A. Hallucinations
- B. Delirium
- C. Delusion
- D. Psychosis
Correct Answer: A
Rationale: Hallucinations involve perceiving things that aren’t present, like seeing snakes, fitting the client’s experience. Delirium is a broader state of confusion that may include hallucinations but isn’t specific to this symptom alone. Delusions are false beliefs, not perceptions. Psychosis is a general term that can include hallucinations but isn’t as precise as the specific symptom described.
A client with Alzheimer's disease has difficulty with bathing and dressing activities. This is an example of which type of loss?
- A. Physical loss
- B. Functional loss
- C. Affective loss
- D. Conative loss
Correct Answer: B
Rationale: Physical loss involves losing a body part or function, not the ability to perform tasks. Functional loss is the reduced ability to perform daily activities like bathing and dressing, common in Alzheimer’s due to cognitive and motor decline. Affective loss is emotional, and conative loss relates to motivation, neither fitting this scenario.
A nurse is caring for a client who was admitted with delirium five days ago. The client seeks permission from the nurse before performing ADLs. Which of the following actions should the nurse take?
- A. Quiz the client with orientation questions.
- B. Allow the client to function independently.
- C. Prepare the client for discharge.
- D. Determine the client's level of awareness.
Correct Answer: D
Rationale: Quizzing assesses but isn’t first. Independence is good but needs assessment first. Discharge is premature without evaluation. Determining awareness guides support, fitting delirium’s fluctuating nature.