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.
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While caring for an 88-year-old client suspected of having dementia, the nurse assesses the client for a common delusional thought. Which of the following would the nurse interpret as a common delusion?
- A. I am the king of the universe.
- B. Creatures are living in my closet.
- C. The government has people following me.
- D. My roommate keeps stealing my clothes.
Correct Answer: D
Rationale: In dementia, a common delusion is the belief that personal belongings are being stolen, often by familiar people like roommates or caregivers, as in option D. Grandiose delusions (option A) or paranoid delusions about the government (option C) are less common in dementia and more associated with other disorders like schizophrenia. Option B is less typical and more fantastical.
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.
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.
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 caring for a 76-year-old patient with a hearing deficit caused by presbycusis. Which of the following would be most appropriate for the nurse to do when communicating with the patient?
- A. Use a higher volume of speech.
- B. Address the client?s family members.
- C. Ask if the client can use sign language.
- D. Use lower pitched tones.
Correct Answer: D
Rationale: Presbycusis, age-related hearing loss, primarily affects high-frequency sounds, making lower-pitched tones easier to hear. Using lower-pitched tones (option D) is most appropriate, as it accommodates the patient?s hearing deficit. Higher volume (option A) may help but can distort sound if too loud. Addressing family members (option B) excludes the patient and is inappropriate. Sign language (option C) is irrelevant unless the patient is trained in it, which is not indicated.