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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.
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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 nurse is caring for a client who has an anxiety disorder and who has begun to hyperventilate, wring her hands, and is pacing the floor continually. Which of the following actions should the nurse take first?
- A. Tell the client you will remain with her.
- B. Take the client to a quiet room.
- C. Ask the client what precipitated this anxiety
- D. Offer the client a prescribed anxiety medication
Correct Answer: A
Rationale: Reassuring presence stabilizes the client emotionally, addressing immediate distress. A quiet room helps but follows reassurance. Asking about triggers is secondary to calming the client. Medication may be needed, but support comes first.
A nurse is caring for a group of older adult clients. Which of the following client findings indicates delirium?
- A. A client expresses dislike of orange juice after reporting earlier that it was a favorite juice.
- B. A client wants to know what type of poison the nurse placed in her medication.
- C. A client asks when family members will be arriving after visiting 1 hr earlier.
- D. A client requests extra blankets when the thermostat in the room indicates 80°F.
Correct Answer: C
Rationale: Changing preferences isn’t delirium-specific. Suspecting poison suggests delusion, not necessarily delirium. Confusion about recent events, like family visits, indicates delirium’s hallmark disorientation. Requesting blankets in a warm room may reflect sensory issues, not delirium directly.
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.
A young adult moves to a new town and is unable to establish relationships because of geographical distance to other towns and a sparsely populated community. This young adult is at greatest risk for which of the following?
- A. Mental illness
- B. Social isolation
- C. Substance abuse
- D. Depression
Correct Answer: B
Rationale: Mental illness is broad and less immediate. Geographical and sparse population factors directly lead to social isolation, the primary risk here. Substance abuse or depression could follow, but isolation is the most direct consequence of the situation.