Chapter 36- Mental Health Assessment of Older Adults My Nursing Test Banks

 

1.

A nurse is caring for a 76-year-old patient with a hearing deficit caused by presbycusis. Which of the following would be most appropriate for the nurse to do when communicating with the patient?

A)

Use a higher volume of speech.

B)

Address the clients family members.

C)

Ask if the client can use sign language.

D)

Use lower pitched tones.

2.

The nurse is caring for a 78-year-old client who is taking an anticholinergic medication and complains of dry mouth. Which of the following would be most appropriate for the nurse to suggest?

A)

Chew hard candies.

B)

Rinse the mouth with a mouthwash.

C)

Use more seasonings on food.

D)

Drink decaffeinated beverages often.

3.

An elderly client tells the nurse that she had been constipated for the last few days and decided to use an over-the-counter fiber laxative that is dissolved in water. When reviewing the use of this laxative with the client, which of the following would the nurse include as a possible side effect?

A)

Diarrhea

B)

Nausea

C)

Flatus

D)

Stomach pain

4.

An 80-year-old client visits the mental health clinic with her daughter. During the assessment process, the client tells the nurse that she is taking an antidepressant, an antibiotic, and an occasional aspirin. Which question would be most important for the nurse to ask?

A)

How much grapefruit juice do you drink on a daily basis?

B)

How much orange juice do you drink on a daily basis?

C)

How much tomato juice do you drink on a daily basis?

D)

How much grape juice do you drink on a daily basis?

5.

While caring for an 88-year-old client suspected of having dementia, the nurse assesses the client for a common delusional thought. Which of the following would the nurse interpret as a common delusion?

A)

I am the king of the universe.

B)

Creatures are living in my closet.

C)

The government has people following me.

D)

My roommate keeps stealing my clothes.

6.

The nurse is assessing a 78-year-old client who lives alone in his own home. To assess the clients instrumental activities of daily living, which question would be most appropriate to ask?

A)

How often do you bathe or shower?

B)

How many times do you change clothes during the day?

C)

How often do you cook meals for yourself?

D)

How often do you go to the store to buy groceries?

7.

The nurse is assessing a client who has a history of heavy drinking and who lost his wife to cancer during the previous year. He reports that he isnt getting as much sleep as he used to when he was younger. Which question would be most appropriate to ask the client to determine if the change in his sleep pattern is related to normal aging or depression?

A)

How much did you sleep when you were younger?

B)

Is it hard for you to fall asleep or remain asleep during the night?

C)

Why do you think you continue to ingest so much alcohol?

D)

What used to help you go to sleep?

8.

A couple is concerned that the husbands father may be developing depression. In questioning the couple, which of the following statements would support their concern?

A)

Dad has been crying off and on now for over 2 weeks since Mom died. Hes also still having trouble sleeping.

B)

Dad is agitated and anxious; hes been that way for a month now since Mom died.

C)

Its been over 2 months now since Mom died, and Dad keeps crying; he cant eat or sleep.

D)

Moms funeral was last week, and Dad hasnt been able to eat or sleep since then.

9.

A nurse is providing an in-service educational program for beginning nurses regarding mental health assessment needs of the older adult. One of the topics addressed is the importance of interviewing family members in addition to the older adult client. The nurse tells the audience that family members are sometimes able to give a more accurate history if the client has memory impairment. The nurse also emphasizes that interviewing family members provides which of the following?

A)

A more accurate picture of the social support resources available

B)

Evaluation of the familys ability to effectively care for the older client

C)

Determination of the extent of the clients memory impairment

D)

A much needed period of respite and support for the family members

10.

Assessment of an older adult client reveals that the client is receiving psychiatric medications. The client states, I get dizzy periodically and have trouble walking. Which of the following should the nurse do first?

A)

Compare the clients baseline blood pressure with the clients current blood pressure.

B)

Instruct the client to stop taking the psychiatric medications.

C)

Interview the clients family about the clients coping skills and current stress level.

D)

Suggest the client periodically use an alcohol-based mouthwash several times a day.

11.

The nurse is planning to assess a clients anxiety level using the Rating Anxiety in Dementia Scale because the client also has dementia. When using this scale which of the following areas would the nurse assess? Select all that apply.

A)

Apprehension

B)

Motor tension

C)

Life satisfaction

D)

Boredom

E)

Autonomic hyperactivity

F)

Worry

12.

A nurse is preparing a presentation for a group of colleagues about suicide and the older adult population. Which of the following would the nurse include in this presentation? Select all that apply.

A)

Suicide is less of a risk in this population as compared with middle-aged adults.

B)

Married African American men are at the greatest risk for suicide in this group.

C)

Depression is the greatest risk factor for suicide in this population group.

D)

White women account for the highest number of suicide deaths in this age group.

E)

Recent behavior changes and loss of support are important assessment areas for suicide risk.

13.

A group of nursing students is reviewing information about age-related changes occurring in cognition and intellectual performance. The students demonstrate understanding of the information when they identify which of the following as a normal cognitive change?

A)

Disorientation to time

B)

Slowed information processing

C)

Diminished executive functioning

D)

Restricted judgment

14.

A nurse is assessing an older adult client. Which of the following would the nurse interpret as most indicative of mental health and wellness?

A)

Keeping social contacts to a minimum

B)

Interacting with others in the environment

C)

Relying solely on family for assistance

D)

Experiencing bereavement

15.

A nurse is using the Neuropsychiatric Inventory to assess an older adult client who is exhibiting behavior problems related to dementia. When using this tool, which of the following would the nurse assess? Select all that apply.

A)

Dysphoria

B)

Inhibition

C)

Apathy

D)

Level of orientation

E)

Memory

F)

Anxiety

16.

A nurse has used the Geriatric Depression Scale (short form) to assess an older adult client for depression. Which score would lead the nurse to suspect that the client is mildly depressed?

A)

3

B)

5

C)

8

D)

13

Answer Key

1.

D

2.

B

3.

C

4.

A

5.

D

6.

D

7.

B

8.

C

9.

B

10.

A

11.

A, B, E, F

12.

C, E

13.

B

14.

B

15.

A, B, C, F

16.

C

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