Ch 38: Mental Health Assessment of Older Adults
a) Depression Pg. 753 Depression is the greatest risk factor for suicide. Individuals who are suicidal often believe that they are a burden to their family, who would be better off without them. Neither delirium nor dementia is the greatest risk factor for suicide in older adults. Bereavement is an important and well-established risk factor for depression.
1. Which of the following is the greatest risk factor for suicide in older adults? a) Depression b) Dementia c) Delirium d) Bereavement
d) Geriatric depression scale Pg. 751-752 The geriatric depression scale (GDS) is a useful screening tool with demonstrated validity and reliability. It was designed as a self-administered test. One advantage is its "yes/no" format, which may easier for older adults to answer.
10. A nurse is aware that a useful screening tool for depression in older adults designed as a self-administered test and using a "yes/no" format is which of the following? a) Wong-Baker FACES scale b) Cornell scale for depression c) Hamilton rating scale for depression d) Geriatric depression scale
b) Experience of chronic pain Pg. 749 Older adults are more likely to experience persistent pain than younger adults because they are at increased risk for chronic illness and may be experiencing the consequences of a lifetime of injuries. For many older adults, chronic pain is a constant companion and contributes to unexplained behavior and personality changes.
11. An older adult is brought to the clinic by the client's child who reports that the client has been demonstrating unexplained behavior and personality changes. The nurse assesses the client, paying special attention to which area? a) Family supports b) Experience of chronic pain c) History of abuse d) Past experiences with losses
b) The client has tremors in both hands Pg. 748 Tremors of the hands may be indicative of a movement disorder and warrants further investigation. If the client is taking an antipsychotic medication, further investigation for tardive dyskinesia are needed as well. It can be expected in the older adult population that the physical examination will happen at a slower pace. The client moving slowly from the wheelchair to the bed is not a concerning observation given the client has limited mobility. Older adult clients may experience compromised hearing leading to trouble hearing high pitches, this is not an abnormal finding. A blood pressure of 125/80 is considered normal and would not warrant further investigation.
12. While conducting a focused assessment of the biological domain in the older adult client with limited mobility, the nurse will need to conduct further investigation of which observable finding? a) The client has a blood pressure measurement of 125/80 b) The client has tremors in both hands c) The client is having difficulty hearing high pitches d) The client is moving slowly from the wheelchair to the bed
c) Afraid to eat as the food is poisoned Pg. 748 The nurse should note any unintentional weight loss of more than 4.5 kg. The nurse must consider such nutrition changes in light of mental health problems.
13. A nurse identifies an unintentional weight loss of 5 kg during a physical assessment of an older adult. Identifying a mental health problem would be indicated or suggested if client response is... a) A decreased appetite b) Client's reduced pleasure in eating as difficulty to smell food c) Afraid to eat as the food is poisoned d) Difficulty swallowing
a) Less likely to report feeling sad or worthless Pg. 751 Older clients are less likely to report feeling sad or worthless than are younger clients.
14. Depression in older adults is overlooked by primary care providers as a result of the older adult's... a) Less likely to report feeling sad or worthless b) Frequent emergency department visits c) Mostly living in extended supportive families d) Minimal contact with primary care providers
c) The client drinks grapefruit juice with breakfast in the morning Pg. 750 When considering potential drug interactions, the nurse should ask the client about his or her consumption of grapefruit juice, which contains naringi. This compound inhbits the CYP3A4 enzyme involved in the metabolism of many medications, including antidepressant medications like sertraline and statin agents such as simvastatin. Protein intake, dairy products and calorie intake are not known to have an impact on the metabolism of these medications, therefore, these would not be a concern when the nurse is investigating the possible factors contributing low efficacy of the client's medications.
15. The nurse is conducting a pharmacological review with an older adult female client. During the interview, the client reports she has recently seen her primary health care provider and that her cholesterol remains high despite taking simvastatin. The client also reports taking her sertraline as prescribed for over five weeks, with minimal improvement in her mood. The nurse should suspect which factor may be impacting the effectiveness of the client's medications? a) The client takes her medications with milk b) The client has low protein intake throughout the day c) The client drinks grapefruit juice with breakfast in the morning d) The client has low daily caloric consumption
a) Rating Anxiety in Dementia Scale (RAIDS) Pg. 752 The nurse should use the RAID scale. The behaviors described by the family members indicate the client may be experiencing anxiety associated with cognitive deterioration and memory loss in dementia. To begin care planning for the client, the nurse must complete the RAIDS with the client to determine if anxiety is contributing to the behavior changes associated with cognitive decline. The GDS and HAM-D may also be useful in assessing the client, however, given the description of the client's behaviors there are fewer indicators of depression manifesting at this time. When dementia is suspected, the SLUMS can help determine the need for further assessment of this disease process.
16. The family member of a male client with dementia tells the nurse the client has been calling the police several times per week stating he is worried about his wife. The client's wife died several years ago. Which instrument should the nurse use in assessing for co-occuring problems with dementia? a) Rating Anxiety in Dementia Scale (RAIDS) b) Hamilton Rating Scale for Depression (HAM-D) c) Geriatric Depression Scale (GDS) d) St. Louis University Mental Status Examination (SLUMS)
a) Unusual stress Pg. 753 In assessing an older client, the nurse should consider unusual stress as indication of high risk for committing suicide.
17. A nurse assessing an older adult for suicide should assess for high risk factors such as... a) Unusual stress b) Family supports c) Frequent church attendance d) Frequent visits to primary care clinics
b) "Has the client been disinterested in activities that are normally enjoyable?" Pg. Many somatic disorders mimic or mask psychiatric disorders. In this case, fatigue related to general medical causes such as anemia and hypothyroidism have been ruled out. The nurse should assess for depression and, in doing so, one of the several questions the nurse should ask is about the loss of pleasure in previously enjoyed activities, also known as anhedonia. Asking about paranoia or suspicion would be appropriate if the client exhibited signs of dementia or schizophrenia. Inquiring about impulsive spending and psychomotor agitation would be appropriate if the nurse suspected Bipolar disorder. These symptoms are much more unlikely to be seen in a client who is reporting fatigue and lack of interest.
18. The daughter of an older adult client is discussing her concerns about the client's health with the nurse. She reports the client continues to be fatigued despite having normal levels of iron and thyroid-stimulating hormone in the lab values report obtained from the client's health care provider. How should the nurse respond? a) "Has the client been paranoid or suspicious of people nearby?" b) "Has the client been disinterested in activities that are normally enjoyable?" c) "Has the client been spending money impulsively?" d) "Has the client been experiencing any psychomotor agitation?"
a) It can lower one's ability to carry out the activities of daily living b) It can impair normal brain functioning e) It can lead to an increased risk of fractures Pg. Alcohol use in older adults has been associated with functional impairments such as it would make it difficult for clients to carry out independent activities of daily living. Alcohol use is also associated with delirium leading to changes in normal brain function and consequent cognitive impairment. The risk of fractures is increased with the use of alcohol in older adults due to the increased incidence of falls associated with it. Heavy alcohol users have substantially increased mortality when compared with light alcohol users. Older adults are more vulnerable to the effects of alcohol, largely related to metabolic changes with change.
19. The nurse is preparing an educational session for older adults regarding the use of alcohol. Which point(s) should the nurse include in the session? Select all that apply. a) It can lower one's ability to carry out the activities of daily living b) It can impair normal brain functioning c) Heavy and light drinkers have the same risk of mortality d) People over age 55 are less vulnerable to the effects of alcohol e) It can lead to an increased risk of fractures
b) CAGE Questionnaire Pg. 749 The use of an assessment tool such as the CAGE questionnaire may be helpful in evaluating this client.
2. A client with alcohol intoxication comes to the mental health clinic. Which of the following evaluative tools would the nurse expect to use when gathering assessment data? a) DSM-IV-TR b) CAGE Questionnaire c) Beck Depression Inventory d) Geriatric Depression Scale
c) "Are you afraid that something bad is going to happen to you?" Pg. 752 Assessment of fear in the client on the GDS assists the nurse in determining if the client is experiencing anxiety. Asking the question if he or she is full of energy assists the nurse in deciding to assess further for signs of mania or hypomania. The nurse would be able to rule out one of the major symptoms of depression if the client responded yes to this question. Asking the client if he or she feels hopeless assists the nurse in deciding whether to complete a risk assessment for suicide. Asking the client if he or she becomes bored often assists in determine to further assess for a decline in cognitive function as apathy can be a warning sign of dementia and/or depression.
20. The nurse is conducting an assessment of an older adult client using the Geriatric Depression Scale (GDS) short form. Which question can assist the nurse in identifying if the client is experiencing anxiety? a) "Do you feel that your situation is hopeless?" b) "Do you often get bored?" c) "Are you afraid that something bad is going to happen to you?" d) "Do you feel full of energy?"
c) "When was your last bowel movement?" Pg. 749 Antipsychotic medication commonly causes constipation. This side effect is even more likely in older adults. The abdominal pain may be related to the constipation; therefore, the nurse must first further explore the client's recent bowel patterns and then continue to investigate the symptoms from there. Although urinary stasis is an adverse side effect of some antipsychotic medications and can cause abdominal pain, the nurse should first rule out constipation as this is more likely given the factors involved in the client's clinical presentation. Once constipation has been ruled out, the nurse should continue to assess the client's overall physical health, however, determining changes related to the initiation of a medication known to cause constipation is a priority and warrants the nurse's attention first.
21. An older adult reports having abdominal pain after starting an antipsychotic medication three weeks prior. Which question is a priority for the nurse to include in the assessment? a) "Have you had a fever recently?" b) "Are you having urinary incontinence?" c) "When was your last bowel movement?" d) " Are you experiencing pain anywhere else?"
a) The client lives at home b) The client lives close to community transportation Pg. 751, 754 Older adults who are able to love at home are usually able to do so as a result of having social support, community support, and being physically and cognitively competent to do so. These are all protective factors against late-onset depression. Access to transportation means that the likelihood of social isolation is lower, another factor that protects against late-onset depression. Having a pet can be considered a "life-saver" for older adults and can protect against loneliness and isolation associated with depression. Compromised hearing can be a normal part of aging and is not a protective or risk factor for depression. Older adult clients who have too little to occupy their time enjoy less mental wellness than those who have opportunities to contribute to the welfare of others.
22. When assessing an older adult client for late-onset depression, the nurse knows which are protective factor(s)? Select all that apply. a) The client lives at home b) The client lives close to community transportation c) The client has compromised hearing d) The client has a pet dog e) The client has lots of free time
b) Present health status Pg. 746-748 Assessment of the biologic domain involves collecting data about past and present health status, physical examination findings, physical functions, pain, and pharmacologic information. Assessment of the psychological domain includes the client's responses to mental health problems, mental status examination, behavioral changes, stress and coping patterns, and risk assessment.
23. Which of the following is a component in the geropsychiatric nursing assessment of the biologic domain? a) Behavioral changes b) Present health status c) Coping patterns d) Mental status examination
b) Contact the client's listed next of kin Pg. 754 The nurse should first contact the client's next of kin, who would be a another source of social support aside from the center, and may be able to provide the needed information about the client's well-being. Asking other people at the center could breach the client's confidentiality if there is a health issue preventing the client from attending the center. The primary health care provider would not be able to provide any information about the client's personal medical issues as this would be a breach in confidentiality. It would not be appropriate to contact the police until the client's next of kin has been contacted, and there are no signs of older adult abuse in this relationship.
24. The manager at the local social center for older adults informs the community health nurse that the client has not attended social programs for one week and is not answering the telephone. Select the most appropriate nursing action. a) Ask other clients at the center about the client b) Contact the client's listed next of kin c) Contact the client's primary health care provider d) Inform the police
a) The client is afraid to eat Pg. 748 There is evidence in this case that the client is experiencing paranoid delusions, as evidenced by the report that she has been agitated and suspicious of the neighbors. The most likely reason for the weight loss is paranoid ideas leading the client to be afraid to eat. Loss of appetite is a common feature associated with depression. The client's recent behavioral changes are more reflective of delusional thinking likely related to cognitive decline rather than depression. It is unlikely that the client is deliberately trying to lose weight. Weight loss is not a normal part of aging and any weight loss over 11 pounds warrants further investigation for cognitive and/ or physiological changes.
25. The nurse is assessing an older female client who has recently lost 11 pounds. The client's family member reports the client has been agitated and suspicious of her neighbors. The nurse should suspect the client has lost weight for which reason? a) The client is afraid to eat b) The client has a loss of appetite c) The client is trying to lose weight d) The client is experiencing age-related weight loss
b) Client has recently been diagnosed with end-stage renal disease (ESRD) c) Client has few available support systems d) Client states nothing is joyful anymore Pg. An older client is at increased risk for suicide due to a multitude of factors. Because this client has experienced a recent loss, been diagnosed with a chronic disease (ESRD), has few support systems, and states that nothing is joyful anymore, the nurse should act and provide immediate referrals to help support the client. Keeping mementos of a loved one and receiving meals on wheels as nutritional support is an appropriate response.
26. A nurse is working with an older client who reports feelings of hopelessness since their spouse passed recently. Which finding(s) would require immediate referral action? Select all that apply. a) Client is receiving meals on wheels on a daily basis b) Client has recently been diagnosed with end-stage renal disease (ESRD) c) Client has few available support systems d) Client states nothing is joyful anymore e) Client keeps mementos of loved one in the bedroom
b) A suicide risk assessment Pg. 753 The client meets several suicide risk criteria. The client is an older adult male who may feel like a burden to his son because there are financial problems in the home. The client has signs and symptoms of depression. Prior to conducting any of the other assessments listed in the alternative options, the nurse should first conduct the suicide risk assessment as safety is the priority.
27. The nurse is assessing an older male adult client who lives in his son's home. The client's son is currently experiencing financial problems. The client himself has been experiencing low mood, poor sleep, and low appetite over the past three weeks. Which assessment should the nurse conduct first? a) An assessment for late-onset depression b) A suicide risk assessment c) Assessment using the standard form Neuropsychiatric Inventory (NPI) d) A St. Louis University Mental Status (SLUMS) Examination
d) Psychological Pg. 746 Assessment of the psychological domain includes the client's responses to mental health problems, mental status examination, behavioral changes, stress and coping patterns, and risk assessment. The mental status examination is not part of the social or biologic domain. There is not a domain per se called functional.
28. When using the biopsychosocial geropsychiatric nursing assessment, the nurse uses the mental status examination as part of her evaluation of a 65-year-old client diagnosed with bipolar disorder. The examination is part of which of the following domains? a) Social b) Biologic c) Functional d) Psychological
a) Xerostomia Pg. 749 Xerostomia is dry mouth and common in older adults. It can impair eating. Dry mouth is a common side effect of many anticholinergic medications and should be addressed by nurses when clients report appetite changes.
29. A client with a heart condition comes to the psychiatric clinic for treatment of depression. The client was recently started on an antidepressant with anticholinergic properties and now reports having a loss of appetite since starting this medication. Which common side effect of the newly prescribed medication would the nurse explain as possibly contributing to the client's loss of appetite? a) Xerostomia b) Polyuria c) Dysphagia d) Polyphagia
b) "What do you do when you are having increased pain?" Pg. 753 Identifying stresses and coping patterns for older adult clients is just as important as it is for younger adults. Asking what a client would do when they experience increased pain provides information about how the client copes with inevitable challenges and, ultimately, the client's level of resilience. The ability to chose adaptive responses will help the client deal well with stressful events. Asking the client if someone helps cook their meals assesses for social support. Asking the client if he or she thinks often about their spouse dying assesses for bereavement and can assist the nurse in identifying signs of depression. Asking the client if he or she has ever struck anyone while they were confused assesses for the neuro-cognitive changes that commonly accompany dementia.
3. The nurse is conducting an interview with an older adult client. When assessing personal coping patterns, which would be most appropriate for the nurse to ask? a) "Have you ever struck someone while you were confused?" b) "What do you do when you are having increased pain?" c) "Do you think often about your spouse dying?" d) "Who helps you cook your meals?"
d) Suicide Pg. 753 Assessing for the risk of suicide with changes in behavior is a priority, specifically in the older adult male client who lives alone in a socially isolated area. The alternate options warrant assessment as well because they can also contribute to changes in behavior; however, assessing for risk of suicide is always a priority.
30. The neighbor of an older male client who lives alone in a rural part of the city has contacted the community health nurse with concerns about a change in the client's behavior. The neighbor reports the client is suddenly withdrawn and has not been tending to his yard, an activity he has always enjoyed. Select the priority nursing assessment. a) Pain b) Cognition c) Mood d) Suicide
a) Antipsychotics Pg. 749 People who have been exposed to conventional antipsychotics, such as Haldol (haloperidol), may have symptoms of tardive dyskinesia.
31. Older adults who have taken a drug from which medication classification may have symptoms of tardive dyskinesia? a) Antipsychotics b) Anticonvulsants c) Antidepressants d) Anti-anxiety medications
c) Depression Pg. 746, 749 Depression is one of the most common mental disorders of older adults. Because depression can be debilitating and can lead to suicide, recognition and early intervention are the keys to avoiding ongoing depressive episodes. Depressive symptoms among older adults are more likely to include vague somatic concerns, cognitive symptoms, hypersomnia, and appetite changes rather than reports of depressed mood. Without additional data, it is not appropriate for nurse to assess the client for anxiety, bipolar disorder, and dysfunctional grief.
32. The nurse provides care to an older adult client who presents with somatic symptoms and a poor appetite. Which mental health disorder does the nurse assess this client for based on the presenting symptoms? a) Bipolar disorder b) Dysfunctional grief c) Depression d) Anxiety
d) Assessment for risk of suicide Pg. 753 The client has multiple factors placing him at risk for suicide. These include being a male older adult, the presence of signs of depression, firearms in the home, abuse of alcohol, low socioeconomic status and chronic pain. Although a full mental status examination is warranted, the priority assessment for the nurse is to determine the client's risk for suicide. The alternative options should be included in the mental status examination after the nurse has confirmed the client is not at risk for suicide.
33. The family member of an older male client tells the nurse that the client, who has chronic pain and poor finances, has had increased alcohol intake for the past two weeks. The client has recently voiced having no desire to go hunting, an activity he once enjoyed. What should be the nurse's priority assessment? a) Assessment for late onset depression b) Assessment of chronic pain c) Assessment for anxiety related to dementia d) Assessment for risk of suicide
a) Facilitate a weekly ice cream social c) Schedule a support group for grief d) Have the dietitian facilitate a cooking group Pg. 753 People obtain their sense of self-worth through their interactions with others in their environment. The correct options bring people together in a socially supportive way. The incorrect options serve to further the social isolation of clients, which can lead to feelings of hopelessness and helplessness in the older adult client.
34. In what way can the nurse encourage clients in a long-term care facility to obtain a sense of self-worth? Select all that apply. a) Facilitate a weekly ice cream social b) Promote time spent in silence c) Schedule a support group for grief d) Have the dietitian facilitate a cooking group e) Discourage multiple daily interactions between clients
b) Changes in relationships due to irritability d) Aggressive outbursts without provocation Pg. 753 If behavior changes occur in older adults, it is most likely family members will notice them before the client does. Behavioral changes that may warrant further assessment for dementia include irritability that may impact relationships and aggressiveness that may manifest with no apparent reason. Although a low intelligence score is associated with Alzheimer's disease, intelligence is rarely assessed in older adults as an indicator of dementia. Taking a longer time to answer questions should not be considered abnormal. Normal cognitive changes during aging include the slowing of information processing. Normal aging can lead to some difficulty with memory retrieval, such as remembering the birthdays of family members.
35. The nurse is preparing a community education session to help family members of older adults recognize signs of dementia. Which teaching point should the nurse include? Select all that apply. a) Trouble remembering birthdays of grandchildren b) Changes in relationships due to irritability c) Taking a longer time to answer questions d) Aggressive outbursts without provocation e) A low score on an intelligence test
a) Suck on hard candies d) Rinse the mouth with a glycerol mouthwash Pg. 749 Xerostomia, or dry mouth, which is common in older adults, also may impair eating. For patients with xerostomia, hard candy or chewing gum may stimulate salivary flow. Glycerol mouthwash can provide as much relief from xerostomia, acting as artificial saliva. The nurse should pay particular attention to those who are currently receiving treatment for mental illnesses, particularly with medications that have anticholinergic properties; modification of the drug regimen may be necessary. Dry mouth is also a side effect of many other anticholinergic medications, such as cimetidine, digoxin, and furosemide. Increasing seasonings or use of decaffeinated beverages would have no effect on dry mouth.
36. A nurse is caring for a client age 78 years who is taking an anticholinergic medication and reports having dry mouth. Which of the following would be most appropriate for the nurse to suggest? Select all that apply. a) Suck on hard candies b) Drink decaffeinated beverages often c) Use more seasonings on food d) Rinse the mouth with a glycerol mouthwash
d) 60 Pg. 752 The term late-onset depression refers to the development after 60 years of age of depression or depressive symptoms that impair functioning. In late-onset depression, the risk for recurrence is relatively high.
37. Late-onset depression typically occurs after which age? a) 70 b) 50 c) 40 d) 60
b) Pneumonia d) Malnutrition e) Asphyxiation Pg. 749 Dysphagia can lead to dehydration, malnutrition, pneumonia, or asphyxiation. Pulmonary emboli and stroke are not associated with dysphagia.
38. A common problem seen in older adults living in nursing homes is dysphagia. Dysphagia can lead to which of the following complications? Select all that apply. a) Stroke b) Pneumonia c) Pulmonary emboli d) Malnutrition e) Asphyxiation
d) Alcohol Pg. 749 The CAGE questionnaire is useful in evaluating alcohol abuse. It does not evaluate opioid, marijuana, or nicotine addiction.
39. The CAGE questionnaire is used to evaluate which type of substance abuse? a) Opioids b) Nicotine c) Marijuana d) Alcohol
a) An increased in physical activity such as walking b) The use of stress reduction measures, including meditation c) A balanced and nutritious diet Pg. 748, 754 The implementation of preventive measures often decreases the need for pharmacologic therapies for older adult clients. These measures include health promotion through proper nutrition (e.g., a balanced and nutritious diet), exercise (e.g., an increase in physical activity, such as walking), and stress reduction (e.g., meditation). The use of Ginkgo biloba, although an alternative therapy, is also considered a pharmacologic intervention. The use of bariatric surgery is not a preventive measure.
4. Which preventative measures should the nurse include to decrease an older adult client's use of pharmacologic therapies? Select all that apply. a) An increased in physical activity such as walking b) The use of stress reduction measures, including meditation c) A balanced and nutritious diet d) The use of bariatric surgery e) The use of Ginkgo biloba
a) Falls c) Dizziness e) Unsteady gait Pg. 748 The nurse should take routine vital signs during the assessment. He or she should note any abnormalities in blood pressure because many psychiatric medications affect blood pressure. Generally, these medications may cause orthostatic hypotension, which can lead to dizziness, unsteady gait, and falls. A baseline blood pressure is needed for future monitoring of orthostatic hypotension. Headache and flushing tend to occur with hypertension, not hypotension.
40. Clients taking some antipsychotic medications can have the side effect of orthostatic hypotension. Which of the following can occur from this side effect? Select all that apply. a) Falls b) Flushing c) Dizziness d) Headache e) Unsteady gait
a) Sepsis b) Acid-base imbalance c) Dehydration d) Hypoxia e) Medications Pg. 746 Changes that affect mental status in older adults not related to mental health problems include acid-base imbalance, dehydration, drugs, electrolyte changes, hypoxia, infections, and sepsis.
41. The nurse working on a unit for older adults suffering from mental health disorders realizes that many things other than a mental condition can affect mental status in the elderly. These include which of the following? Select all that apply. a) Sepsis b) Acid-base imbalance c) Dehydration d) Hypoxia e) Medications f) Spirituality
b) Depression Pg. 753 When caring for the older client with mental health problems, it is always important to consider the client's potential to commit suicide. Depression is the greatest risk factor for suicide.
5. The nurse is conducting a risk assessment with an older adult client. Which finding would be most concerning regarding the risk for suicide? a) Mania b) Depression c) Cognitive impairment d) Memory changes
a) "Do you feel like you need to cut down on your drinking?" Pg. 749 The "C" in the CAGE questionnaire asks the client if they have ever felt that they need to cut down on their consumption of alcohol. The nurse is using the CAGE to assess for alcohol use or abuse because the sleep disturbance and unexplained chronic pain are two symptoms consistent with this problem. The alternate options are not questions that are included on the CAGE questionnaire.
6. The nurse is assessing an older adult client who has sleep disturbances and unexplained chronic pain. The nurse includes the CAGE questionnaire in the assessment. Which question should the nurse ask? a) "Do you feel like you need to cut down on your drinking?" b) "Who are your social supports?" c) "Have you ever been physically abused?" d) "Have you had a recent death in your family?"
a) Identify which could affect mental health problems Pg. 748 The nurse must identify chronic health problems that could affect mental health care.
7. During an assessment of an older adult, a nurse must identify chronic health problems in order to... a) Identify which could affect mental health problems b) Link direct result of physical problems to mental health problems c) Provide treatment for physical problems not addressed otherwise d) Use information for cognitive testing
a) Depression Pg. 753 Depression is the greatest risk factor for suicide. People who are suicidal often believe that they are a burden to their family, who would be better off without them. Although substance abuse, anxiety, and stress may contribute to suicide, they are not one of the greatest risk factors.
8. The nurse is attending a seminar on prevention of suicide. The presenter is discussing risk factors for suicide, stating that which of the following is the greatest risk factor? a) Depression b) Stress c) Anxiety d) Substance abuse
d) Excessive gas e) Bloating Pg. 749 Older adults are more likely to experience constipation. Although the addition of fiber is recommended, it may also cause bloating and excessive gas production.
9. A nurse working with elderly clients knows the importance of adequate fluid intake and increasing fiber consumption to help prevent constipation. However, the nurse also is aware that increased fiber may cause which of the following side effects in these clients? Select all that apply. a) Increased appetite b) Infrequent urination c) Decreased taste buds d) Excessive gas e) Bloating