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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.
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A community mental health nurse plans an educational program for staff members at a home health agency that specializes in the care of older adults. What topic is of high priority?
- A. Identifying depression in older adults
- B. Providing cost-effective foot care for older adults
- C. Identifying nutritional deficiencies in older adults
- D. Psychosocial stimulation for those who live alone
Correct Answer: A
Rationale: Depression is the most common, most debilitating, and also most treatable psychiatric disorder in the older adult. Home health staff are often better versed in the physical aspects of care and less knowledgeable about mental health topics. Statistics show that older adult patients with mental health problems are less likely than young adults to be diagnosed accurately.
An older patient reports drinking a six-pack of beer daily. The patient tells the community health nurse, 'I've been having trouble with my arthritis lately, so I take acetaminophen four times a day for pain.' What are the nurse's priority interventions?
- A. Inquiring about sleep disturbances caused by mixing alcohol and analgesic medications
- B. Determining the safety of the daily acetaminophen dose the patient is ingesting
- C. Advising the patient of harmful effects of alcohol and acetaminophen on the liver
- D. Suggesting an increase in the acetaminophen dose because alcohol produces faster excretion
- E. Assessing the patient for declining functional status associated with medication-induced dementia
Correct Answer: B,C
Rationale: The toxicity of acetaminophen is enhanced by alcohol and age-related decrease in clearance, requiring assessment of the dose and education on the dangers of combined use.
An advance directive gives valid direction to health care providers when a patient is demonstrating what characteristic?
- A. Aggression
- B. Dehydration
- C. Ineffective verbally communicate
- D. Unable to make health care decisions
Correct Answer: D
Rationale: Advance directives are invoked when patients are unable to make their own decisions.
A 79-year-old white man tells a visiting nurse, 'I've been feeling sad lately. My family and friends are all dead. My money is running out, and my health is failing.' How should the nurse analyze this comment?
- A. Normal negativity of older adults
- B. Evidence of suicide risk
- C. A cry for sympathy
- D. Normal grieving
Correct Answer: B
Rationale: The patient describes the loss of significant others, economic insecurity, and declining health, which are risk factors for suicide, especially in older adult white men.
Recognizing the risk for acquired immunodeficiency syndrome (AIDS) among older adults, nurses should provide health teaching focused on what?
- A. Discouraging sexual expression
- B. Using birth control measures
- C. Avoiding blood transfusions
- D. Encouraging condom use
Correct Answer: D
Rationale: Safe sex continues to be important and should be taught to the older adult population. Condom use is diminished in postmenopausal women, which places older adults at risk for AIDS and other sexually transmitted diseases.