Chapter 38: Mental Health Assessment of Older Adults

Late-onset depression typically occurs after which age? a) 70 b) 40 c) 60 d) 50

c) 60

A nurse caring for an elderly client knows that quality of life is important to people of all age groups. Many older adults, however, define quality of life as which of the following? a) Contentment with how they have lived b) Retirement benefits c) Material possessions d) Physical health

a) Contentment with how they have lived

A screening tool for depression that is designed as a self-administered test with use of "yes/no" answers is referred to as ... a) HAM-D b) Mini mental status examination c) CSDD d) GDS

d) GDS

Which of the following is a component in the geropsychiatric nursing assessment of the biologic domain? a) Behavioral changes b) Coping patterns c) Mental status examination d) Present health status

d) Present health status

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) "What do you do when you are having increased pain?" b) "Who helps you cook your meals?" c) "Do you think often about your spouse dying?" d) "Have you ever struck someone while you were confused?"

a) "What do you do when you are having increased pain?"

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) Bloating b) Increased appetite c) Decreased taste buds d) Infrequent urination e) Excessive gas

a) Bloating e) Excessive gas

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 states nothing is joyful anymore. b) Client is receiving meals on wheels on a daily basis. c) Client has few available support systems. d) Client has recently been diagnosed with end-stage renal disease (ESRD). e) Client keeps mementos of loved one in the bedroom.

a) Client states nothing is joyful anymore. c) Client has few available support systems. d) Client has recently been diagnosed with end-stage renal disease (ESRD).

A nurse is assessing the mental status of an older adult. Which change would the nurse need to keep in mind as affecting the client's mental status? Select all that apply. a) Electrolyte changes b) Fluid overload c) Hypoxia d) Hypothyroidism e) Infection

a) Electrolyte changes c) Hypoxia d) Hypothyroidism e) Infection

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) Geriatric depression scale b) Wong-Baker FACES scale c) Hamilton rating scale for depression d) Cornell scale for depression

a) Geriatric depression scale

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 impair normal brain functioning. b) Heavy and light drinkers have the same risk of mortality. c) It can lead to an increased risk of fractures. d) People over age 55 are less vulnerable to the effects of alcohol. e) It can lower one's ability to carry out the activities of daily living.

a) It can impair normal brain functioning. c) It can lead to an increased risk of fractures. e) It can lower one's ability to carry out the activities of daily living.

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) Malnutrition b) Pneumonia c) Asphyxiation d) Pulmonary emboli e) Stroke

a) Malnutrition b) Pneumonia c) Asphyxiation

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) Medications b) Acid-base imbalance c) Hypoxia d) Dehydration e) Sepsis f) Spirituality

a) Medications b) Acid-base imbalance c) Hypoxia d) Dehydration e) Sepsis

Which activities by the nurse can explore the spirituality of the homeless client? Select all that apply. a) Pray with the client. b) Read devotional material if asked by the client. c) Share personal religious stories. d) Ask the client about God. e) Attend a religious service.

a) Pray with the client. b) Read devotional material if asked by the client. e) Attend a religious service.

The fasting blood sugar of an older adult client is 130 mg/dl. The nurse reviews the client's pharmacological records and suspects which medication may be a contributing factor? a) Risperidone b) Amlodipine c) Simvastatin d) Low-dose acetylsalicylic acid

a) Risperidone

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) Suicide b) Pain c) Mood d) Cognition

a) Suicide

Which of the following is the priority for the older adult experiencing a mental health problem? a) Suicide assessment b) Social support c) Appropriate shelter d) Ability to complete ADLs

a) Suicide assessment

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 close to community transportation. b) The client has compromised hearing. c) The client has a pet dog. d) The client lives at home. e) The client has lots of free time.

a) The client lives close to community transportation. d) The client lives at home.

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 bariatric surgery c) the use of stress reduction measures, including meditation d) a balanced and nutritious diet e) the use of Ginkgo biloba

a) an increased in physical activity such as walking c) the use of stress reduction measures, including meditation d) a balanced and nutritious diet

Which food should the nurse include in the plan of care for an older adult client as part of a healthy lifestyle to prevent illness and promote well-being? a) apples b) steak c) hamburger d) potatoes

a) apples

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) depression b) bipolar disorder c) anxiety d) dysfunctional grief

a) depression

One way in which the expression of depressive symptoms in older adults may differ from the presentation in young adults is ... a) older adults may somatize, or discuss their depressive symptoms in terms of physical symptoms or aches/pains. b) older adults remain close to their families and thus become depressed over daily family issues, whereas younger adults often leave their families of origin. c) older adults tend to hold all their feelings in, whereas younger adults do not. d) older adults may appear less suicidal than a younger adult who is depressed.

a) older adults may somatize, or discuss their depressive symptoms in terms of physical symptoms or aches/pains.

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) "Are you afraid that something bad is going to happen to you?" c) "Do you often get bored?" d) "Do you feel full of energy?"

b) "Are you afraid that something bad is going to happen to you?"

The nurse is seeing an older adult client who reports having difficulty falling and staying asleep. Which assessment question should the nurse ask? Select all that apply. a) "Are you catching colds easier than you used to?" b) "Can you list your medications for me?" c) "Do you have an overactive bladder?" d) "How are your relationships with your family?" e) "Are you feeling lonely these days?"

b) "Can you list your medications for me?" c) "Do you have an overactive bladder?" d) "How are your relationships with your family?" e) "Are you feeling lonely these days?"

The nurse is seeing an older adult female client with no previous history of psychiatric symptoms. The client's son told the nurse the client has voiced beliefs that her son is "someone in disguise." The client has not been willing to let her son come to her home. Which assessment question should the nurse ask first? a) "Has your sleep been disrupted since you've been having these thoughts?" b) "Can you tell me more about these thoughts you are having about your son?" c) "Do you want me to contact the authorities to investigate this further?" d) "Have you been taking all of your prescribed medications correctly?"

b) "Can you tell me more about these thoughts you are having about your son?"

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) Client's reduced pleasure in eating as difficulty to smell food b) Afraid to eat as the food is poisoned c) Difficulty swallowing d) A decreased appetite

b) Afraid to eat as the food is poisoned

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

b) CAGE Questionnaire

Which of the following is the best validated scale for clients with dementia? a) Hamilton Rating Scale b) Cornell Scale for Depression in Dementia (CSDD) c) Rating Anxiety in Dementia (RAID) d) Geriatric Depression Scale (GDS)

b) Cornell Scale for Depression in Dementia (CSDD)

A nurse is conducting an assessment of an older adult. The initial assessment reveals cognitive changes. The nurse conducts a further assessment, suspecting which disorder as being associated with these cognitive changes? a) Anxiety disorders b) Delirium c) Panic disorders d) Depression

b) Delirium

The neuropsychiatric Inventory (NPI) was developed in 1994 to assess behavior problems associated with which disorder? a) Delirium b) Dementia c) Schizophrenia d) Depression

b) Dementia

During an assessment of an older adult, a nurse must identify chronic health problems in order to ... a) Provide treatment for physical problems not addressed otherwise b) Identify which could affect mental health problems c) Link direct result of physical problems to mental health problems d) Use information for cognitive testing

b) Identify which could affect mental health problems

The nurse has arranged a meeting with a dietitian at the local clinic for an older female client who lives independently. The client tells the nurse she is unable to attend the appointment. The nurse suspects the client's inability to attend is most likely related to which barrier? a) A fall in the home b) Lack of transportation c) Late onset depression d) Elder abuse

b) Lack of transportation

A nurse is conducting an geropsychiataric assessment of an older adult client. Which component would the nurse evaluate when assessing the client's social domain? Select all that apply. a) Risk assessment b) Legal information c) Mental status examination d) Quality of life e) Spiritual assessment

b) Legal information d) Quality of life e) Spiritual assessment

Assessing an older adult, the nurse learns that one factor contributing to the client remaining mentally healthy and living alone is the individual's ... a) Pain threshold b) Pet c) Proximity to grocery store d) Availability of hospital emergency departments in close proximity

b) Pet

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) Functional b) Psychological c) Biologic d) Social

b) Psychological

Which of the following is accurate with regard to suicide in older adults? a) Rates decrease with age b) Rates increase with age c) Rates are higher among older white women d) Rates are higher among married men ages 42 to 77 years

b) Rates increase with age

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) Promote time spent in silence. b) Schedule a support group for grief. c) Have the dietitian facilitate a cooking group. d) Facilitate a weekly ice cream social. e) Discourage multiple daily interactions between clients.

b) Schedule a support group for grief. c) Have the dietitian facilitate a cooking group. d) Facilitate a weekly ice cream social.

Which of the following are considered indications of high risk for committing suicide in the older adult? Select all that apply. a) Active lifestyle b) Social Isolation c) Burden to family d) Firearms in the home e) Married

b) Social Isolation c) Burden to family d) Firearms in the home

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) Drink decaffeinated beverages often. b) Suck on hard candies. c) Rinse the mouth with a glycerol mouthwash. d) Use more seasonings on food.

b) Suck on hard candies. c) Rinse the mouth with a glycerol mouthwash.

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) Cognition b) Suicide c) Mood d) Pain

b) Suicide

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 drinks grapefruit juice with breakfast in the morning. c) The client has low protein intake throughout the day. d) The client has low daily caloric consumption.

b) The client drinks grapefruit juice with breakfast in the morning.

The nurse is assessing an older adult client who has sleep disturbances and unexplained chronic pain. The nurse includes the CAGE questionnare in the assessment. Which question should the nurse ask? a) "Who are your social supports?" b) "Have you had a recent death in your family?" c) "Do you feel like you need to cut down on your drinking?" d) "Have you ever been physically abused?"

c) "Do you feel like you need to cut down on your drinking?"

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 spending money impulsively?" b) "Has the client been paranoid or suspicious of people nearby?" c) "Has the client been disinterested in activities that are normally enjoyable?" d) "Has the client been experiencing any psychomotor agitation?"

c) "Has the client been disinterested in activities that are normally enjoyable?"

A nurse is using the standard version of the Neuro-psychiatric Inventory (NPI) to conduct an assessment of an older adult client. Which client is the nurse most likely assessing using this tool? a) A client who is suspicious of people living in his nursing home b) A client who feels lonely at home since his wife died c) A client who lives at home and is hearing voices d) A client who lives in a nursing home and is having excessive worry

c) A client who lives at home and is hearing voices

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) Assessment using the standard form b) Neuropsychiatric Inventory (NPI) c) A suicide risk assessment d) An assessment for late-onset depression e) A St. Louis University Mental Status (SLUMS) Examination

c) A suicide risk assessment

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) Taking a longer time to answer questions b) Trouble remembering birthdays of grandchildren c) Aggressive outbursts without provocation d) A low score on an intelligence test e) Changes in relationships due to irritability

c) Aggressive outbursts without provocation e) Changes in relationships due to irritability

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 anxiety related to dementia b) Assessment for late onset depression c) Assessment for risk of suicide d) Assessment of chronic pain

c) Assessment for risk of suicide

When completing a biopsychosocial assessment on a geriatric client, the nurse must consider which component of the psychological domain? a) Support systems b) Family assessment c) Behavioral changes d) Physical functions

c) Behavioral changes

The nurse is conducting a risk assessment with an older adult client. Which finding would be most concerning regarding the risk for suicide? a) Cognitive impairment b) Mania c) Depression d) Memory changes

c) Depression

A major barrier to an elderly person seeking adequate mental health care may be due to the myth that says what? a) Elderly clients tend to get frustrated and confused negotiating care within the array of mental health services available. b) Older people too often seek health assistance, particularly for mental or emotional disorders. c) Depression, confusion, memory loss, and other mental or emotional problems are simply part of normal aging. d) Often healthcare professionals tend to exaggerate the effects of mental problems.

c) Depression, confusion, memory loss, and other mental or emotional problems are simply part of normal aging.

To assist in resolving polypharmacy issues in older adults, nurses are encouraged to implement the "all" system. This refers to what? a) Encouraging all clients to bring all over-the-counter medications to all physician visits b) Encouraging all clients to tell all physicians about all of their medications c) Encouraging all clients to bring all their medications to all physician visits d) Encouraging all clients to tell all healthvcare providers about all over-the-counter medications

c) Encouraging all clients to bring all their medications to all physician visits

A nurse interviewing an elderly client with a mental health disorder uses a lower voice pitch for which of the following reasons? a) High-pitched voices are overly authoritarian and can scare vulnerable patients. b) High-pitched voices are irritating to the mentally ill. c) High-pitched sounds are lost with presbycusis. d) High-pitched voices often denote sarcasm, which can insult patients.

c) High-pitched sounds are lost with presbycusis.

Depression in older adults is overlooked by primary care providers as a result of the older adult's ... a) Minimal contact with primary care providers b) Mostly living in extended supportive families c) Less likely to report feeling sad or worthless d) Frequent emergency department visits

c) Less likely to report feeling sad or worthless

Which of the following is the priority for the older adult experiencing a mental health problem? a) Ability to complete ADLs b) Social support c) Suicide assessment d) Appropriate shelter

c) Suicide assessment

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) Headache b) Flushing c) Unsteady gait d) Falls e) Dizziness

c) Unsteady gait d) Falls e) Dizziness

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) Dysphagia b) Polyuria c) Xerostomia d) Polyphagia

c) Xerostomia

A nurse is using the Geriatric Depression Scale (GDS) to assess an older adult client. A positive response to which question on the scale should prompt the nurse to conduct a suicide risk assessment? a) "Do you feel you have more problems with memory than most?" b) "Do you often get bored?" c) "Are you afraid that something bad is going to happen to you?" d) "Do you feel that your situation is hopeless?"

d) "Do you feel that your situation is hopeless?"

While conducting the mental status assessment of an older male adult client who has been brought to the clinic by his daughter, the client states, "I'm not crazy, stop asking me these questions!" What is the nurse's best response? a) "Maybe we can talk about other problems you are having?" b) "I need to determine if you are at risk to yourself or others, can you help me?" c) "Your daughter would not bring you here if she was not worried about you, would she?" d) "It sounds like you are feeling frustrated right now, is that true?"

d) "It sounds like you are feeling frustrated right now, is that true?"

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 experiencing pain anywhere else?" c) "Are you having urinary incontinence?" d) "When was your last bowel movement?"

d) "When was your last bowel movement?"

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 for anxiety related to dementia c) Assessment of chronic pain d) Assessment for risk of suicide

d) Assessment for risk of suicide

Which client population has the greatest number of suicide deaths in the older age group? a) Caucasian women b) African-American women c) Asian-American men d) Caucasian men

d) Caucasian men

When interviewing a client, it is important for the nurse to understand that deafness can be mistaken for which of the following impairments? a) Perceptual deficit b) Social impairment c) Low intelligence d) Cognitive dysfunction

d) Cognitive dysfunction

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) Contact the client's primary health care provider. b) Inform the police. c) Ask other clients at the center about the client. d) Contact the client's listed next of kin.

d) Contact the client's listed next of kin.

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) Hamilton Rating Scale for Depression (HAM-D) b) Geriatric Depression Scale (GDS) c) St. Louis University Mental Status Examination (SLUMS) d) Rating Anxiety in Dementia Scale (RAIDS)

d) Rating Anxiety in Dementia Scale (RAIDS)

A psychiatric technician greets an older adult client by saying, "Hello, Bob. My name is Matt. I have to take some information from you. First, how many years young are you?" The nurse overhearing this exchange should do what? a) Interrupt the technician to point out that he should address the client by his surname. b) Do nothing. Even though the technician's approach is a little too familiar, the client should be able to understand that the technician is trying to be respectful. c) Do nothing. The technician's friendly manner will put the client at ease. d) Take the technician aside to explain that his words are inadvertently disrespectful.

d) Take the technician aside to explain that his words are inadvertently disrespectful.

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 trying to lose weight. b) The client has a loss of appetite. c) The client is experiencing age-related weight loss. d) The client is afraid to eat.

d) The client is afraid to eat.