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The nurse is caring for a 78-year-old client who is taking an anticholinergic medication and complains of dry mouth. Which of the following would be most appropriate for the nurse to suggest?
- A. Chew hard candies.
- B. Rinse the mouth with a mouthwash.
- C. Use more seasonings on food.
- D. Drink decaffeinated beverages often.
Correct Answer: A
Rationale: Chewing hard candies, especially sugar-free ones, stimulates saliva production, which helps alleviate dry mouth caused by anticholinergic medications. Mouthwash (option B) may not address dryness and could irritate the mouth if alcohol-based. Seasonings (option C) do not relieve dry mouth. Decaffeinated beverages (option D) may help with hydration but are less effective than stimulating saliva.
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A group of nursing students is reviewing information about age-related changes occurring in cognition and intellectual performance. The students demonstrate understanding of the information when they identify which of the following as a normal cognitive change?
- A. Disorientation to time
- B. Slowed information processing
- C. Diminished executive functioning
- D. Restricted judgment
Correct Answer: B
Rationale: Slowed information processing (option B) is a normal age-related cognitive change, as processing speed declines with aging but does not impair overall function significantly. Disorientation to time (A), diminished executive functioning (C), and restricted judgment (D) are more indicative of pathological conditions like dementia, not normal aging.
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.
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 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.
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.