Nokea
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.
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An 80-year-old patient has difficulty walking because of arthritis and says, 'It's awful to be old. Every day is a struggle. No one cares about old people.' Which is the nurse's most therapeutic response?
- A. Everyone here cares about old people. That's why we work here.'
- B. It sounds like you're having a difficult time. Tell me about it.'
- C. Let's not focus on the negative. Tell me something good.'
- D. You are still able to get around, and your mind is alert.'
Correct Answer: B
Rationale: The nurse uses therapeutic communication and empathic understanding to encourage the patient to express frustration and clarify the 'struggle' for the nurse.
A nurse asks the following questions while assessing an older adult. The nurse will add the Geriatric Depression Scale as part of the assessment if the patient answers 'yes' to which question?
- A. Would you say your mood is often sad?'
- B. Are you having any trouble with your memory?'
- C. Have you noticed an increase in your alcohol use?'
- D. Do you often experience moderate-to-severe pain?'
Correct Answer: A
Rationale: Sadness may be a symptom of depression. Sad moods occurring with regularity should signal the need to assess further for other symptoms of depression.
A 78-year-old nursing home resident diagnosed with hypertension and cardiac disease is usually alert and oriented. This morning, however, the resident says, 'My family visited during the night. They stood by the bed and talked to me.' In reality, the patient's family lives 200 miles away. The nurse should first suspect what as the trigger for the resident's experience?
- A. A side effect associated with medications.
- B. Early Alzheimer's disease associated with advanced age.
- C. A transient ischemic attack and developed sensory perceptual alterations.
- D. Previously unidentified alcohol abuse and is beginning alcohol withdrawal delirium.
Correct Answer: A
Rationale: A resident taking medications is at high risk for becoming confused because of medication side effects, drug interactions, and delayed excretion.
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.
A health care provider writes these new prescriptions for a resident in a skilled care facility: '2 g sodium diet; restraint as needed; limit fluids to 2000 mL daily; 1 dose milk of magnesia 30 mL orally if no bowel movement occurs for 3 days.' Which prescription should the nurse question?
- A. Restraint
- B. Fluid restriction
- C. Milk of magnesia
- D. Sodium restriction
Correct Answer: A
Rationale: Restraints may be applied only on the written order of the health care provider that specifies the duration during which the restraints can be used. The Joint Commission guidelines and Omnibus Budget Reconciliation Act regulations also mandate a number of other conditions that must be considered and documented before restraints are used.