Nokea
A nurse is providing an in-service educational program for beginning nurses regarding mental health assessment needs of the older adult. One of the topics addressed is the importance of interviewing family members in addition to the older adult client. The nurse tells the audience that family members are sometimes able to give a more accurate history if the client has memory impairment. The nurse also emphasizes that interviewing family members provides which of the following?
- A. A more accurate picture of the social support resources available
- B. Evaluation of the family?s ability to effectively care for the older client
- C. Determination of the extent of the client?s memory impairment
- D. A much needed period of respite and support for the family members
Correct Answer: A
Rationale: Interviewing family members provides a clearer picture of the client?s social support resources (option A), which is critical for assessing the older adult?s ability to manage mental health challenges. Option B focuses on caregiver ability, which is secondary. Option C is partially correct but less comprehensive, as memory impairment is only one aspect. Option D is incorrect, as interviews are not primarily for family respite.
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A nurse is preparing a presentation for a group of colleagues about suicide and the older adult population. Which of the following would the nurse include in this presentation? Select all that apply.
- A. Suicide is less of a risk in this population as compared with middle-aged adults.
- B. Married African American men are at the greatest risk for suicide in this group.
- C. Depression is the greatest risk factor for suicide in this population group.
- D. White women account for the highest number of suicide deaths in this age group.
- E. Recent behavior changes and loss of support are important assessment areas for suicide risk.
Correct Answer: C,E
Rationale: Depression (C) is the greatest risk factor for suicide in older adults, as it significantly increases vulnerability. Recent behavior changes and loss of support (E) are critical to assess, as they signal increased risk. Option A is incorrect, as older adults have higher suicide rates than middle-aged adults. Option B is false, as White men, not African American men, are at higher risk. Option D is incorrect, as White men, not women, have the highest suicide rates in this group.
A nurse is using the Neuropsychiatric Inventory to assess an older adult client who is exhibiting behavior problems related to dementia. When using this tool, which of the following would the nurse assess? Select all that apply.
- A. Dysphoria
- B. Inhibition
- C. Apathy
- D. Level of orientation
- E. Memory
- F. Anxiety
Correct Answer: A,C,F
Rationale: The Neuropsychiatric Inventory assesses behavioral and psychological symptoms in dementia, including dysphoria (A), apathy (C), and anxiety (F). Inhibition (B) is not a standard domain, though disinhibition is. Level of orientation (D) and memory (E) are cognitive functions assessed by other tools, not the Neuropsychiatric Inventory, which focuses on behavioral symptoms.
An elderly client tells the nurse that she had been constipated for the last few days and decided to use an over-the-counter fiber laxative that is dissolved in water. When reviewing the use of this laxative with the client, which of the following would the nurse include as a possible side effect?
- A. Diarrhea
- B. Nausea
- C. Flatus
- D. Stomach pain
Correct Answer: C
Rationale: Fiber laxatives, such as psyllium, increase bulk in the stool and can cause flatus (gas) as a common side effect due to fermentation in the gut. Diarrhea (option A) may occur with overuse but is less common. Nausea (option B) and stomach pain (option D) are less directly associated with fiber laxatives compared to flatus.
The nurse is assessing a client who has a history of heavy drinking and who lost his wife to cancer during the previous year. He reports that he isn?t getting as much sleep as he used to when he was younger. Which question would be most appropriate to ask the client to determine if the change in his sleep pattern is related to normal aging or depression?
- A. How much did you sleep when you were younger?
- B. Is it hard for you to fall asleep or remain asleep during the night?
- C. Why do you think you continue to ingest so much alcohol?
- D. What used to help you go to sleep?
Correct Answer: B
Rationale: Difficulty falling or staying asleep (option B) is a key symptom of depression, especially in the context of recent loss and heavy drinking, which can exacerbate depressive symptoms. Normal aging may reduce sleep duration slightly, but insomnia is more indicative of depression. Options A, C, and D provide background but do not directly differentiate between aging and depression.
Assessment of an older adult client reveals that the client is receiving psychiatric medications. The client states, 'I get dizzy periodically and have trouble walking.' Which of the following should the nurse do first?
- A. Compare the client?s baseline blood pressure with the client?s current blood pressure.
- B. Instruct the client to stop taking the psychiatric medications.
- C. Interview the client?s family about the client?s coping skills and current stress level.
- D. Suggest the client periodically use an alcohol-based mouthwash several times a day.
Correct Answer: A
Rationale: Dizziness and walking difficulties in an older adult on psychiatric medications may indicate orthostatic hypotension, a common side effect. Comparing baseline and current blood pressure (option A) is the first step to assess this. Stopping medications (option B) is premature without evidence. Interviewing family (option C) is secondary to physical assessment. Mouthwash (option D) is irrelevant to the symptoms.