Chapter 07 My Nursing Test Banks

Tabloski Gerontological Nursing, 3/e
Chapter 07

Question 1

Type: MCSA

During an interview, the nurse notes that an older patient is having mild difficulty with some words and forgets the names of people. The patient is alert, oriented to time, person, and place, and makes appropriate responses. What does the nurse determine this patients cognitive changes to mean?

1. Normal signs of aging

2. Early symptoms of dementia

3. Indicators of depression in the elderly

4. Memory impairment that may be related to cerebral ischemia

Correct Answer: 1

Rationale 1: Cognitive changes vary widely in the elderly; however, older people will not suffer significant memory impairment. Many may experience mild problems with word finding and remembering names. The changes observed in this patient are normal signs of aging.
Reference: Page 164

Rationale 2: A problem with finding words and forgetting names is not a symptom of dementia.
Reference: Page 164

Rationale 3: A problem with finding words and forgetting names is not a symptom of depression.
Reference: Page 164

Rationale 4: A problem with finding words and forgetting names is not related to cerebral ischemia.
Reference: Page 164

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 1. Describe age-related changes that affect psychological and cognitive functioning.

Question 2

Type: MCSA

An older patient wakes up from sleep, confused, and insists a family member is in the other room. What information within the patients medical record should the nurse consider as a source of the patients confusion?

1. The patient is elderly.

2. The patients spouse recently died.

3. The patient received pain medication.

4. The patient has a history of cardiac disease.

Correct Answer: 3

Rationale 1: Age does not cause confusion.
Reference: Page 166

Rationale 2: The loss of a loved one may cause depression but is not identified as a reason for confusion.
Reference: Page 166

Rationale 3: Certain medications like sleeping pills, tranquilizers, and some pain medications can cause symptoms similar to dementia.
Reference: Page 166

Rationale 4: Cardiac disease alone is not known to cause confusion.
Reference: Page 166

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 4. Examine risk factors that influence cognitive functioning in older adults.

Question 3

Type: MCSA

The nurse is providing discharge instructions to an older patient that includes the administration of insulin. Which strategy will the nurse use when instructing this patient to adjust to the normal changes experienced with aging?

1. Giving written materials to compensate for short-term memory losses

2. Using tools that repeat the information until the information is understood

3. Considering holding sessions for longer periods than usual so the patient can learn

4. Providing instruction to relatives so that the patient will not need to learn everything

Correct Answer: 2

Rationale 1: Short-term memory, or primary memory, remains relatively stable when aging.
Reference: Page 164

Rationale 2: Normal age-related changes include a slowing of information processing, which results in the need for repetition of information.
Reference: Page 164

Rationale 3: Another age-related change includes the inability to maintain sustained attention. Long teaching sessions would not be appropriate.
Reference: Page 164

Rationale 4: Assuming the patient cannot learn everything is stereotypical of the aging process.
Reference: Page 164

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 1. Describe age-related changes that affect psychological and cognitive functioning.

Question 4

Type: MCSA

The daughter of an older patient tells the nurse that the patient used to be a wonderful cook but now cannot remember how to use a blender. What does this information indicate to the nurse?

1. Short-term memory loss

2. Long-term memory loss

3. Normal cognitive change in an older person

4. Cognitive change that requires further assessment

Correct Answer: 4

Rationale 1: Short-term memory remains relatively stable when aging.
Reference: Page 165

Rationale 2: Long-term memory remains relatively stable when aging.
Reference: Page 165

Rationale 3: Normal, healthy older persons should not forget how to use a common object or item.
Reference: Page 165

Rationale 4: Normal, healthy older persons who forget what an item is used for or how to use it should be referred for further evaluation and treatment.
Reference: Page 165

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 1. Describe age-related changes that affect psychological and cognitive functioning.

Question 5

Type: MCMA

An older patient is concerned about remembering to take prescribed medications. What strategies should the nurse recommend to this patient?

Standard Text: Select all that apply.

1. Rely on habit to take the medication.

2. Use an assistive device such as a pillbox.

3. Suggest a family member provide the medication.

4. Discuss moving to an assisted living facility for safety.

5. Discuss reducing the number of medications with the physician.

Correct Answer: 1,2

Rationale 1: Reliance on habit helps to reduce the chances of forgetting vital information, such as taking prescribed medications.
Reference: Page 165

Rationale 2: Using assistive devices such as pillboxes helps to reduce the chances of forgetting vital information, such as taking prescribed medications.
Reference: Page 165

Rationale 3: Suggesting that a family member provide the medication would be an unnecessary burden to the family.
Reference: Page 165

Rationale 4: There is no reason for the patient to be transferred to an assisted living facility.
Reference: Page 165

Rationale 5: Consulting the healthcare provider to alter the drug schedule may be necessary but would be considered after other strategies have been tried.
Reference: Page 165

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 1. Describe age-related changes that affect psychological and cognitive functioning.

Question 6

Type: MCSA

An older patient with cardiac disease is having sleep problems and insomnia. Of what health problem should the nurse consider these manifestations?

1. Normal signs of aging

2. Predictive signs of respiratory disease

3. Symptoms of the negative effects of stress

4. Expected manifestations of cardiac disease

Correct Answer: 3

Rationale 1: Sleep problems and insomnia are not normal signs of aging.
Reference: Page 169

Rationale 2: There is no information to suggest that sleep problems and insomnia are predictive signs of respiratory disease.
Reference: Page 169

Rationale 3: Symptoms that indicate an older person may be suffering negative effects of stress include sleep problems and insomnia.
Reference: Page 169

Rationale 4: There is no information to suggest that sleep problems and insomnia are expected manifestations of cardiac disease.
Reference: Page 169

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Basic Care and Comfort

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 2. Explain the impact of age-related changes on stress and coping.

Question 7

Type: MCMA

An older African American patient is diagnosed with a mental health problem that has been untreated for many years. What does the nurse realize as reasons for this patients problem not being adequately treated?

Standard Text: Select all that apply.

1. Ageism

2. Poverty

3. Cultural bias

4. Discrimination

5. Respecting medical personnel

Correct Answer: 1,2,3,4

Rationale 1: Minority elders are at risk for mental health problems because of ageism or a negative stereotype toward older adults.
Reference: Page 167

Rationale 2: One factor that contributes to poor mental health in minority elders is poverty.
Reference: Page 167

Rationale 3: Minority elders are at risk for mental health problems because of cultural bias.
Reference: Page 167

Rationale 4: One factor that contributes to poor mental health in minority elders is discrimination.
Reference: Page 167

Rationale 5: Respecting medical personnel is not identified as being a factor that contributes to poor mental health in minority elders. Most minority elders mistrust medical personnel which can contribute to poor mental health in this population.
Reference: Page 167

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 3. Detect risk factors for high levels of stress, poor coping, and impaired mental health, including alcoholism, stress-related disorders, and depression.

Question 8

Type: MCSA

An older patient being treated for abdominal pain reports no relief of pain and other somatic complaints after receiving adequate pain medication. What additional intervention is indicated for this patient?

1. Reviewing the patients lab values

2. Contacting the family to talk to the patient

3. Further assessment and treatment for depression

4. Obtaining an order for different pain medication

Correct Answer: 3

Rationale 1: The laboratory values are of no significance in this patient situation.
Reference: Page 172

Rationale 2: The family may be ineffective in meeting the patients psychological needs.
Reference: Page 172

Rationale 3: The major signs of depression in the older person include multiple somatic complaints and reports of persistent chronic pain.
Reference: Page 172

Rationale 4: Obtaining different pain medication would not treat potential psychological problems.
Reference: Page 172

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 3. Detect risk factors for high levels of stress, poor coping, and impaired mental health, including alcoholism, stress-related disorders, and depression.

Question 9

Type: MCMA

An older patient is demonstrating signs of paranoia. What does the nurse identify as possible causes for this type of psychosis?

Standard Text: Select all that apply.

1. Delirium

2. Hearing loss

3. Physical illness

4. Social isolation

5. Cognitive impairment

Correct Answer: 1,2,4,5

Rationale 1: Risk factors for paranoia include delirium.
Reference: Page 170

Rationale 2: Risk factors for the development of paranoia include hearing loss.
Reference: Page 170

Rationale 3: Risk factors for the development of adjustment disorder include physical illness.
Reference: Page 170

Rationale 4: Risk factors for the development of paranoia include social isolation.
Reference: Page 170

Rationale 5: Risk factors for the development of paranoia include cognitive impairment.
Reference: Page 170

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 3. Detect risk factors for high levels of stress, poor coping, and impaired mental health, including alcoholism, stress-related disorders, and depression.

Question 10

Type: MCSA

An older patient tells the nurse that alcohol is used occasionally to combat stress. The patient is a recent widow, retired, and admits to feeling worthless at times. The nurse realizes this patient is at risk for which health problem?

1. Suicide

2. Paranoia

3. Dementia

4. Liver failure

Correct Answer: 1

Rationale 1: Older persons over the age of 65 have the highest suicide rates of all age groups. A major risk factor for suicide is depression. An inappropriate feeling of worthlessness is a symptom of depression.
Reference: Page 175

Rationale 2: The patient is not demonstrating symptoms of paranoia.
Reference: Page 175

Rationale 3: The patient is not demonstrating symptoms of dementia.
Reference: Page 175

Rationale 4: Occasional use of alcohol does not necessarily indicate that the patient is at risk for liver failure.
Reference: Page 175

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 3. Detect risk factors for high levels of stress, poor coping, and impaired mental health, including alcoholism, stress-related disorders, and depression.

Question 11

Type: MCMA

Which cognitive changes does the nurse recognize as being normal in an older patient?

Standard Text: Select all that apply.

1. Decline in the ability to draw

2. Decrease in size of vocabulary

3. Difficulty filtering out irrelevant information

4. Difficulty switching attention from one person to another

5. Needing to repeat information to the patient several times

Correct Answer: 1,3,4,5

Rationale 1: A decline in visuospatial task ability such as drawing declines with aging.
Reference: Page 164

Rationale 2: Vocabulary improves with age.
Reference: Page 164

Rationale 3: The ability to filter out irrelevant information declines with age.
Reference: Page 164

Rationale 4: The ability to switch attention between people declines with age.
Reference: Page 164

Rationale 5: Information-processing speed declines with age, necessitating the need to repeat information to the patient several times.
Reference: Page 164

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 1. Describe age-related changes that affect psychological and cognitive functioning.

Question 12

Type: MCMA

What should the nurse instruct an older patient to do to cope with age-associated cognitive changes?

Standard Text: Select all that apply.

1. Read daily.

2. Write notes to self.

3. Play computer games.

4. Learn memory enhancement techniques.

5. Expect others to call attention to any gaffes.

Correct Answer: 1,2,3,4

Rationale 1: One way to cope with age-associated cognitive changes is to read daily in order to keep the mind challenged and mentally active.
Reference: Page 165

Rationale 2: One way to cope with age-associated cognitive changes is to write notes to self.
Reference: Page 165

Rationale 3: One way to cope with age-associated cognitive changes is to play computer games.
Reference: Page 165

Rationale 4: One way to cope with age-associated cognitive changes is to learn memory enhancement techniques.
Reference: Page 165

Rationale 5: The patient should stay positive and laugh at oneself when appropriate and not expect others to call attention to any gaffes.
Reference: Page 165

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 5. Define appropriate nursing interventions directed toward assisting the older adult to develop coping resources, use effective coping mechanisms, and minimize the functional consequences of stress.

Question 13

Type: MCSA

The son of an older patient is concerned about the patients ongoing forgetfulness and asks the nurse to explain what could be wrong with the patient. How should the nurse respond to the son?

1. Memory difficulties are hard for family members to deal with.

2. My parents are the same age as yours, and they cant remember anything.

3. Forgetfulness is common in older adults. Its nothing you need to worry about.

4. Memory difficulties can be due to underlying issues including anxiety, chronic pain, or depression.

Correct Answer: 4

Rationale 1: Memory difficulties are difficult for family members to deal with, but this is not the most appropriate statement at this time. The nurse is discounting the sons feelings.
Reference: Page 170

Rationale 2: The nurse is showing sympathy with the statement about the parents but is not addressing the sons feelings.
Reference: Page 170

Rationale 3: Forgetfulness is common in older adults, but this statement is not therapeutic.
Reference: Page 170

Rationale 4: Cognitive changes can be due to anxiety, chronic pain, depression, or Alzheimers disease.
Reference: Page 170

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 4. Examine risk factors that influence cognitive functioning in older adults.

Question 14

Type: MCMA

The nurse is preparing an educational program for nursing assistants at a long-term care facility about psychiatric issues in older patients. Which symptoms should the nurse include?

Standard Text: Select all that apply.

1. Flat affect

2. Fear of death

3. Changes in sleep patterns

4. Delusions and hallucinations

5. Difficulty in performing ADLs

Correct Answer: 1,2,3,4

Rationale 1: A psychiatric symptom that should be investigated and not written off as a normal change of aging includes problems with emotional expression such as a flat affect.
Reference: Page 170

Rationale 2: A psychiatric symptom that should be investigated and not written off as a normal change of aging includes a fear of death.
Reference: Page 170

Rationale 3: A psychiatric symptom that should be investigated and not written off as a normal change of aging includes changes in sleep patterns.
Reference: Page 170

Rationale 4: A psychiatric symptom that should be investigated and not written off as a normal change of aging includes delusions and hallucinations.
Reference: Page 170

Rationale 5: Difficulty in performing ADLs does not necessarily indicate a psychiatric issue.
Reference: Page 170

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 4. Examine risk factors that influence cognitive functioning in older adults.

Question 15

Type: MCMA

The nurse is concerned that an older patient has a problem related to regular alcohol consumption. What did the nurse assess in this patient?

Standard Text: Select all that apply.

1. Anxiety

2. Malnutrition

3. Social isolation

4. Bruises from falling

5. Dependence on family members

Correct Answer: 1,2,3,4

Rationale 1: Problems related to excessive or regular alcohol consumption include anxiety.
Reference: Page 177

Rationale 2: Problems related to excessive or regular alcohol consumption include malnutrition or failure to prepare and eat an adequate diet.
Reference: Page 177

Rationale 3: Problems related to excessive or regular alcohol consumption include social isolation because of avoiding people who do not drink or are judgmental.
Reference: Page 177

Rationale 4: Problems related to excessive or regular alcohol consumption include recurrent bruises from falls.
Reference: Page 177

Rationale 5: Problems related to excessive or regular alcohol consumption do not include dependence on family members.
Reference: Page 177

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 3. Detect risk factors for high levels of stress, poor coping, and impaired mental health, including alcoholism, stress-related disorders, and depression.

Question 16

Type: MCSA

An older patients spouse passed away 4 years ago; however, the patient still sets a place at the dinner table for the spouse and has never removed any clothing or other personal items from the home. What does the nurse suspect the patient is experiencing?

1. Normal grief

2. Hopelessness

3. Survivor guilt

4. Pathological grief

Correct Answer: 4

Rationale 1: Normal grief is that which lasts within a 2-year time frame.
Reference: Page 171

Rationale 2: Hopelessness is when the patient sees no hope in life. This is not what the patient is experiencing.
Reference: Page 171

Rationale 3: Survivor guilt is associated with a traumatic event where a person survives when another loved one does not.
Reference: Page 171

Rationale 4: Grief persisting longer than 2 years is considered pathological in the United States.
Reference: Page 171

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 3. Detect risk factors for high levels of stress, poor coping, and impaired mental health, including alcoholism, stress-related disorders, and depression.

Question 17

Type: MCMA

The nurse is preparing a presentation on grief. What information should be included regarding factors that can affect the duration and course of grieving?

Standard Text: Select all that apply.

1. Centrality of loss

2. Nature of the death

3. Health of the survivor

4. Cultural and ethnic influences

5. Survivors religious or spiritual belief system

Correct Answer: 1,2,3,5

Rationale 1: Factors than can affect the duration and course of grieving include the centrality of the loss.
Reference: Page 171

Rationale 2: Factors than can affect the duration and course of grieving include the nature of the death.
Reference: Page 171

Rationale 3: Factors than can affect the duration and course of grieving include the health of the survivor.
Reference: Page 171

Rationale 4: Factors than can affect the duration and course of grieving do not include cultural and ethnic influences.
Reference: Page 171

Rationale 5: Factors than can affect the duration and course of grieving include the survivors religious or spiritual belief system.
Reference: Page 171

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 3. Detect risk factors for high levels of stress, poor coping, and impaired mental health, including alcoholism, stress-related disorders, and depression.

Question 18

Type: MCSA

During an assessment, the nurse learns that an older patient experiences much stress and feels the heart racing at times. The nurse explains that this is the fight-or-flight response and is associated with which body chemical?

1. Serotonin

2. Dopamine

3. Epinephrine

4. Acetylcholine

Correct Answer: 3

Rationale 1: Serotonin is associated with sleep and depression.
Reference: Page 169

Rationale 2: Dopamine is associated with schizophrenia.
Reference: Page 169

Rationale 3: The fight-or-flight response stimulates epinephrine release and increases pulse, blood pressure, blood glucose, and muscle tension.
Reference: Page 169

Rationale 4: Acetylcholine is associated with Alzheimers disease.
Reference: Page 169

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 3. Detect risk factors for high levels of stress, poor coping, and impaired mental health, including alcoholism, stress-related disorders, and depression.

Question 19

Type: MCSA

While organizing a walking program at an assisted living facility, one resident asks why older people should exercise. Which response would be the best for the nurse to make?

1. You arent too old to exercise.

2. Exercise can help increase your blood pressure.

3. Exercise has not been shown to have any benefits for people over 80.

4. Exercise can help reduce the negative effects of stress, which can impact your physical health.

Correct Answer: 4

Rationale 1: The statement You arent too old to exercise does not answer the residents question.
Reference: Page 181

Rationale 2: Exercise helps to decrease and not increase blood pressure.
Reference: Page 181

Rationale 3: Exercise is beneficial for all people of all ages.
Reference: Page 181

Rationale 4: Exercise can help to break the cycle of long-term negative effects of stress and reduce the harmful effects of elevated cortisol levels caused by stress.
Reference: Page 181

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 5. Define appropriate nursing interventions directed toward assisting the older adult to develop coping resources, use effective coping mechanisms, and minimize the functional consequences of stress.

Question 20

Type: MCSA

The nurse caring for older patients in a long-term care facility is organizing a depression screening program for the residents. How will this screening program benefit the older patients?

1. Differentiates dysthymia from delirium

2. Supports care expectations of the older patients family members

3. Depression symptoms are often associated with chronic illness and pain.

4. Depression is the easiest mood disorder to detect and treat in older patients.

Correct Answer: 3

Rationale 1: Screening an older patient for depression is not done to differentiate dysthymia from delirium. Older patients may experience persistent feelings of sadness but not meet the criteria for depression.
Reference: Page 172

Rationale 2: Screening older patients for depression is not done to support care expectations of older patients family members. This action helps to identify those patients who need intervention to treat depression.
Reference: Page 172

Rationale 3: Depression is the mental health problem of greatest frequency and magnitude in the older population. The risk of depression in the older person increases with other illnesses and when ability to function becomes limited. Symptoms of depression are often associated with chronic illness and pain.
Reference: Page 172

Rationale 4: Depression in older adults is often undetected and untreated. Primary healthcare providers are often not vigilant or consistent in their diagnosis of depression and may fail to make the diagnosis.
Reference: Page 172

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 7. Formulate interventions directed toward alleviating risk factors for late-life depression, treating depression in older adults, and preventing suicide.

Question 21

Type: MCSA

Which observation should indicate to the nurse to assess an older patient for depression?

1. Flat affect

2. Hyperactivity

3. Racing thoughts

4. Pressured speech

Correct Answer: 1

Rationale 1: A flat affect or having minimal or no reaction to emotion is one clinical manifestation of depression in an older patient.
Reference: Page 172

Rationale 2: Hyperactivity is a manifestation of mania.
Reference: Page 172

Rationale 3: Racing thoughts is a manifestation of mania.
Reference: Page 172

Rationale 4: Pressured speech is when words cannot be stated quickly enough and is a manifestation of mania.
Reference: Page 172

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 3. Detect risk factors for high levels of stress, poor coping, and impaired mental health, including alcoholism, stress-related disorders, and depression.

Question 22

Type: MCMA

The nurse is planning an educational session on suicide in the older patient population. What information should the nurse include in this presentation?

Standard Text: Select all that apply.

1. Suicide rates are the highest in teens.

2. A patient should never be questioned about suicide intent.

3. Suicide rates are the highest in people age 65 and older.

4. An older person who contemplates suicide is more likely to complete the act than a younger person.

5. Approximately 70% of older adults who commit suicide had visited their primary care physician within the previous month.

Correct Answer: 3,4,5

Rationale 1: Older persons age 65 and over have the highest suicide rates of all age groups.
Reference: Page 175

Rationale 2: Suicide intent is part of the nursing assessment for depression.
Reference: Page 175

Rationale 3: Older persons age 65 and over have the highest suicide rates of all age groups.
Reference: Page 175

Rationale 4: An older person who contemplates suicide is more likely to complete the act than a younger person because older people often employ lethal methods when attempting suicide, experience greater social isolation, and generally have poorer recuperative capacity, which makes them less likely to recover from a suicide attempt.
Reference: Page 175

Rationale 5: Approximately 70% of older adults who commit suicide had visited their primary care physician within the previous month.
Reference: Page 175

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 7. Formulate interventions directed toward alleviating risk factors for late-life depression, treating depression in older adults, and preventing suicide.

Question 23

Type: MCSA

Which statement made by an older patient indicates to the nurse that the patient might be contemplating suicide?

1. I wish I could stop all of this pain.

2. God will take me when its my time.

3. Im ready to go when God calls me.

4. Im no use to anyone. I might as well be dead.

Correct Answer: 4

Rationale 1: Expressing a desire to have pain end does not indicate that an older patient is contemplating suicide.
Reference: Page 176

Rationale 2: A statement that reflects Gods will is not expressing suicidal intentions.
Reference: Page 176

Rationale 3: A statement that reflects Gods will is not expressing suicidal intentions.
Reference: Page 176

Rationale 4: The statement that reflects uselessness and being dead is one that should be analyzed for suicidal intentions.
Reference: Page 176

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 7. Formulate interventions directed toward alleviating risk factors for late-life depression, treating depression in older adults, and preventing suicide.

Question 24

Type: MCSA

An older patient is prescribed a monoamine oxidase inhibitor (MAOI) medication. Which meal choice indicates that the patient needs further education regarding this medication?

1. Pepperoni pizza and diet soda

2. Baked chicken, green beans, and cherry pie

3. Fried chicken, creamed corn, and French fries

4. Chicken salad on a croissant, carrot sticks, and fresh fruit

Correct Answer: 1

Rationale 1: Because these drugs inhibit the metabolism of norepinephrine, hypertensive crisis can occur if they are administered with other drugs or food that raise blood pressure such as anticholinergics, stimulants, and foods containing tyramine including red wine, cheese, beer, bologna, pepperoni, liver, raisins, and bananas.
Reference: Page 184

Rationale 2: None of these food items contain tyramine, which should be avoided in the patient receiving a MAOI.
Reference: Page 184

Rationale 3: None of these food items contain tyramine, which should be avoided in the patient receiving a MAOI.
Reference: Page 184

Rationale 4: None of these food items contain tyramine, which should be avoided in the patient receiving a MAOI.
Reference: Page 184

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 5. Define appropriate nursing interventions directed toward assisting the older adult to develop coping resources, use effective coping mechanisms, and minimize the functional consequences of stress.

Question 25

Type: MCSA

The nurse is planning care for an older patient diagnosed with major depression who states that voices are telling the patient to kill himself. Which nursing diagnosis would be a priority for this patient?

1. Social isolation

2. Risk for suicide

3. Disturbed sleep pattern

4. Altered sensory perception

Correct Answer: 2

Rationale 1: Social isolation might be causing the patient to hear voices; however, this would not be the priority diagnosis at this time.
Reference: Page 184

Rationale 2: The patient is hearing voices that are telling him to kill himself. This patient is at risk for suicide.
Reference: Page 184

Rationale 3: The patient may or may not have disturbed sleep. This is not the priority diagnosis for the patient at this time.
Reference: Page 184

Rationale 4: Even though the patient is hearing voices, which would be an alteration in sensory perception, the voices are telling the patient to kill himself. This is not the priority diagnosis for the patient at this time.
Reference: Page 184

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 7. Formulate interventions directed toward alleviating risk factors for late-life depression, treating depression in older adults, and preventing suicide.

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