Nokea
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.
You may also like to solve these questions
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.
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.
A nurse is preparing a presentation for a group of colleagues about suicide and the older adult population. Which of the following would the nurse include in this presentation? Select all that apply.
- A. Suicide is less of a risk in this population as compared with middle-aged adults.
- B. Married African American men are at the greatest risk for suicide in this group.
- C. Depression is the greatest risk factor for suicide in this population group.
- D. White women account for the highest number of suicide deaths in this age group.
- E. Recent behavior changes and loss of support are important assessment areas for suicide risk.
Correct Answer: C,E
Rationale: Depression (C) is the greatest risk factor for suicide in older adults, as it significantly increases vulnerability. Recent behavior changes and loss of support (E) are critical to assess, as they signal increased risk. Option A is incorrect, as older adults have higher suicide rates than middle-aged adults. Option B is false, as White men, not African American men, are at higher risk. Option D is incorrect, as White men, not women, have the highest suicide rates in this group.
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.
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.