Mental Health- PrepU Chapter 38
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?
"Are you afraid that something bad is going to happen to you?"
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?
"When was your last bowel movement?"
The nurse is assessing an older adult client who reports increased alcohol use over the past month. When assessing for physical changes associated with increased alcohol use in the older adult, which assessment question should the nurse include? Select all that apply.
- "How often do you experience pain?" - "Have you had any seizures recently?" - "Have you had any changes in your vision?" - "How is your sleep lately?"
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.
- Bloating - Excessive gas
A group of nurses working in the local long-term care facility is reviewing information about mental health problems in older clients. The nurses demostrate understanding of the information when they list which problem as being most common in older adults? Select all that apply.
- Depression - Anxiety disorders - Dementia
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.
- Facilitate a weekly ice cream social. - Have the dietitian facilitate a cooking group. - Schedule a support group for grief.
When working with an elderly client who has a mental disorder, the nurse recognizes the importance of interviewing the client as well as his or her family members. The main reasons for talking to family members is for which of the following purposes? Select all that apply.
- Family members often notice changes that clients fail to notice in themselves. - Interviewing relatives gives the nurse an opportunity to evaluate caregivers themselves.
Which of the following are considered indications of high risk for committing suicide in the older adult? Select all that apply.
- Firearms in the home - Social Isolation - Burden to family
A nursing instructor is teaching students about changes seen in the elderly. Which of the following functions does the instructor tell the students do not change with age? Select all that apply.
- Intellectual function - Capacity for change
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.
- It can lower one's ability to carry out the activities of daily living. - It can impair normal brain functioning. - It can lead to an increased risk of fractures.
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.
- Pneumonia - Asphyxiation - Malnutrition
Which preventative measures should the nurse include to decrease an older adult client's use of pharmacologic therapies? Select all that apply.
- a balanced and nutritious diet - an increased in physical activity such as walking - the use of stress reduction measures, including meditation
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 suicide risk assessment
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 ...
Afraid to eat as the food is poisoned
A major barrier to an elderly person seeking adequate mental health care may be due to the myth that says what?
Depression, confusion, memory loss, and other mental or emotional problems are simply part of normal aging.
Older adults who have taken a drug from which medication classification may have symptoms of tardive dyskinesia?
Antipsychotics
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?
Assessment for risk of suicide
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?
CAGE Questionnaire
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.
Contact the client's listed next of kin
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.
Contact the client's listed next of kin.
Which of the following is the best validated scale for clients with dementia?
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?
Delirium
The neuropsychiatric Inventory (NPI) was developed in 1994 to assess behavior problems associated with which disorder?
Dementia
When beginning the mental status examination of an older female client, the nurse notes the client is holding her knee and grimacing.The nurse also notes the client has hand tremors. Which action should the nurse take first?
Determine the client's ability to participate in the assessment.
The nurse should utilize the local senior center to provide which intervention to older adults in the community?
Discuss strategies to prevent falls at home.
A nurse assessing a client's social support should ask the following ...
Do you have any one special person you could call if you needed help?
To assist in resolving polypharmacy issues in older adults, nurses are encouraged to implement the "all" system. This refers to what?
Encouraging all clients to bring all their medications to all physician visits
A nurse working with an older client whose family is concerned about the present living arrangements asks the nurse about placement in an assisted living facility (ALF). The older client maintains the ability to perform ADLs in the present residence and wants to stay. What is the bestnursing response?
Explore options that may allow the older adult client to remain in the residence.
A screening tool for depression that is designed as a self-administered test with use of "yes/no" answers is referred to as ...
GDS
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?
Geriatric depression scale
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?
Lack of transportation
Which of the following is accurate with regard to suicide in older adults?
Rates increase with age
The nurse is conducting a pharmacological assessment of an older adult who has a longstanding history of schizophrenia. The client history indicates the client was prescribed clozapine for over 10 years. What is the nurse most likely to find in the client history as a result of taking this medication?
Seizures
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?
Take the technician aside to explain that his words are inadvertently disrespectful.
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?
The client drinks grapefruit juice with breakfast in the morning.
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?
The client is afraid to eat.
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?
Xerostomia
