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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.
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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.
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 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 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.