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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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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.
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.
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.
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.
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.