Nokea
The nurse is preparing to assess a 78-year-old patient who has been diagnosed with major depression. Which of the following would the nurse expect to assess as a normal finding?
- A. Decrease in body fat
- B. Increased muscle mass
- C. Dulled taste sensation
- D. Enhanced visual acuity
Correct Answer: C
Rationale: Dulled taste sensation is a normal age-related change in older adults due to reduced sensory function. Decreased body fat and increased muscle mass are not typical, and visual acuity typically declines, not enhances, with age.
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While assessing an older adult patient for mental health issues, the nurse pays special attention to the patient?s sensory function based on the understanding of which of the following?
- A. Most older adults follow a specific pattern of decline in functioning leading to gradual onset of problems.
- B. Sensory decline may affect the individual?s ability to process information, possibly influencing the findings of the mental status examination.
- C. Diminished sensory function can lead to changes in other body systems that may affect the individual?s reaction to prescribed medications.
- D. Changes in the senses can result in changes in cognitive abilities that mimic the manifestations of mental disorders.
Correct Answer: B
Rationale: Sensory decline (e.g., hearing, vision) can impair information processing, affecting mental status examination results. Patterns of decline vary, sensory changes don?t directly alter other systems for medication reactions, and cognitive mimicry is possible but less primary.
A nurse is preparing to conduct an assessment of a 79-year-old woman who has come to the clinic for evaluation. When performing this assessment, which of the following would be most appropriate for the nurse to do? Select all that apply.
- A. Dim any lights that appear too bright.
- B. Face the patient from the side.
- C. Use short, simple sentences.
- D. Focus on one topic at a time.
- E. Speak slowly in a shouting tone.
Correct Answer: A,C,D
Rationale: Appropriate assessment techniques for older adults include dimming bright lights (A) to reduce glare, using short, simple sentences (C), and focusing on one topic (D) to accommodate sensory and cognitive changes. Facing from the side (B) is less effective than facing directly, and shouting (E) may be inappropriate or distressing.
The nurse is working as part of a team to help reduce the stigma attached to mental health treatment for the older adult population. Which of the following would be most appropriate to do to achieve this outcome?
- A. Provide education about mental health and mental disorders.
- B. Initiate screening programs for symptoms.
- C. Ensure older adults received integrated community care.
- D. Institute a wide range of social support services.
Correct Answer: A
Rationale: Providing education about mental health and disorders directly reduces stigma by increasing understanding and normalizing treatment. Screening, integrated care, and social support are valuable but less directly address stigma.
A nurse is reviewing the medical records of several older adult patients who have come to the clinic for evaluation. The nurse would classify a patient of which age as being in the middle-old stage?
- A. 66-year-old adult
- B. 70-year-old adult
- C. 78-year-old adult
- D. 86-year-old adult
Correct Answer: C
Rationale: The middle-old stage typically spans ages 75?84. A 78-year-old fits this category, while 66 and 70 are young-old, and 86 is old-old.
The nurse is working with a patient whose mobility is impaired secondary to a fall that resulted in a broken hip. In addition, the patient, who has diabetes, is developing problems with vision and hearing. The patient seems increasingly withdrawn and depressed. The nurse determines that the patient is at risk for spiritual distress. Which intervention would be most appropriate?
- A. Encourage the patient to talk about significant childhood religious experiences.
- B. Offer to take the patient to a revival the nurse?s church is holding in the community.
- C. Read to the patient Bible passages that seem particularly relevant to the patient?s case.
- D. Explore what the mobility, sight, and hearing changes mean to the patient.
Correct Answer: D
Rationale: Exploring the meaning of the patient?s losses addresses spiritual distress by focusing on their personal values and coping, which is patient-centered. Religious interventions (A, B, C) may not align with the patient?s beliefs and could be inappropriate.