Nokea
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.
You may also like to solve these questions
A couple is concerned that the husband?s father may be developing depression. In questioning the couple, which of the following statements would support their concern?
- A. Dad has been crying off and on now for over 2 weeks since Mom died. He?s also still having trouble sleeping.
- B. Dad is agitated and anxious; he?s been that way for a month now since Mom died.
- C. It?s been over 2 months now since Mom died, and Dad keeps crying; he can?t eat or sleep.
- D. Mom?s funeral was last week, and Dad hasn?t been able to eat or sleep since then.
Correct Answer: C
Rationale: Persistent crying, inability to eat, and sleep difficulties for over 2 months (option C) strongly suggest depression, as these symptoms exceed normal grief duration (typically lessening within 2 months). Option A (2 weeks) and option D (1 week) reflect acute grief, which is more expected. Option B (agitation and anxiety) is less specific to depression and could indicate other conditions.
A nurse is assessing an older adult client. Which of the following would the nurse interpret as most indicative of mental health and wellness?
- A. Keeping social contacts to a minimum
- B. Interacting with others in the environment
- C. Relying solely on family for assistance
- D. Experiencing bereavement
Correct Answer: B
Rationale: Interacting with others in the environment (option B) is most indicative of mental health and wellness, as it reflects social engagement, a key component of psychological well-being. Keeping social contacts to a minimum (A) or relying solely on family (C) suggests isolation or dependence, which are less healthy. Bereavement (D) is a normal response but not an indicator of wellness.
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.
The nurse is assessing a 78-year-old client who lives alone in his own home. To assess the client?s instrumental activities of daily living, which question would be most appropriate to ask?
- A. How often do you bathe or shower?
- B. How many times do you change clothes during the day?
- C. How often do you cook meals for yourself?
- D. How often do you go to the store to buy groceries?
Correct Answer: C
Rationale: Instrumental activities of daily living (IADLs) include complex tasks like cooking, shopping, and managing finances. Asking about cooking meals (option C) directly assesses an IADL. Bathing (option A) and changing clothes (option B) are basic activities of daily living (ADLs). Grocery shopping (option D) is an IADL but is less specific than cooking for assessing daily functioning.