Nokea
An 80-year-old client visits the mental health clinic with her daughter. During the assessment process, the client tells the nurse that she is taking an antidepressant, an antibiotic, and an occasional aspirin. Which question would be most important for the nurse to ask?
- A. How much grapefruit juice do you drink on a daily basis?
- B. How much orange juice do you drink on a daily basis?
- C. How much tomato juice do you drink on a daily basis?
- D. How much grape juice do you drink on a daily basis?
Correct Answer: A
Rationale: Grapefruit juice can interact with many medications, including some antidepressants and antibiotics, by inhibiting the cytochrome P450 enzyme system, potentially leading to increased drug levels and toxicity. Orange, tomato, and grape juices (options B, C, D) do not have significant interactions with these medications, making grapefruit juice the most critical to assess.
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A nurse has used the Geriatric Depression Scale (short form) to assess an older adult client for depression. Which score would lead the nurse to suspect that the client is mildly depressed?
- A. 3
- B. 5
- C. 8
- D. 13
Correct Answer: C
Rationale: The Geriatric Depression Scale (short form) has 15 questions, with scores of 5?8 indicating mild depression and 9?15 indicating moderate to severe depression. A score of 8 (option C) falls within the mild depression range. Scores of 3 and 5 (options A and B) are below the threshold, and 13 (option D) indicates moderate to severe depression.
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.
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.
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 planning to assess a client?s anxiety level using the Rating Anxiety in Dementia Scale because the client also has dementia. When using this scale which of the following areas would the nurse assess? Select all that apply.
- A. Apprehension
- B. Motor tension
- C. Life satisfaction
- D. Boredom
- E. Autonomic hyperactivity
- F. Worry
Correct Answer: A,B,E,F
Rationale: The Rating Anxiety in Dementia Scale assesses anxiety symptoms in dementia patients, including apprehension (A), motor tension (B), autonomic hyperactivity (E), and worry (F). Life satisfaction (C) and boredom (D) are not specific components of this scale, which focuses on anxiety-related behaviors and physiological signs.