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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.
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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 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.
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.
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.
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.