Nursing > Exam > Chapter 31: Older Adults Halter: Varcarolis’ Foundations of Psychiatric Mental Health Nursing: A C (All)

Chapter 31: Older Adults Halter: Varcarolis’ Foundations of Psychiatric Mental Health Nursing: A Clinical Approach, 8th Edition

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1. A student nurse visiting a senior center says, ―It‘s depressing to see these old people. They are weak and frail. I doubt any of them can engage in a discussion.‖ The student is expressing a... . reality. b. ageism. c. empathy. d. vulnerability. ANS: B Ageism is a bias against older people because of their age. None of the other options applies to the ideas expressed by the student. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 31-14 TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 2. A nurse plans an educational program for staff of a home health agency specializing in care of the elderly. Which topic is the highest priority to include? a. Pain assessment techniques for older adults b. Psychosocial stimulation for those who live alone c. Preparation of psychiatric advance directives in the elderly d. Ways to manage disinhibition in elderly persons with dementia ANS: A The topic of greatest immediacy is the assessment of pain in older adults. Unmanaged pain can precipitate other problems, such as substance abuse and depression. Elderly patients are less likely to be accurately diagnosed and adequately treated for pain. The distracters are unrelated or of lesser importance. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) REF: Pages 31-9, 10 TOP: Nursing Process: Planning MSC: Client Needs: Physiological Integrity 3. Select the best comment for a nurse to begin an interview with an elderly patient. a. ―I am a nurse. Are you familiar with what nurses do?‖ b. ―Hello. I am going to ask you some questions to get to know you better.‖ c. ―You look comfortable and ready to participate in an admission interview. Shall we get started?‖ d. ―Hello. My name is and I am a nurse. How you would like to be addressed by staff?‖ testbanks_and_xanax ANS: D The correct opening identifies the nurse‘s role and politely seeks direction for addressing the patient in a way that will make him or her comfortable. This is particularly important when a considerable age difference exists between the nurse and the patient. The nurse should address patients by name and not assume patients want to be called by a first name. The nurse should always introduce self. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Pages 31-17, 18, 21, 45 (Box 31-8) TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity 4. Which information is most important to obtain during assessment of an older adult diagnosed with health problems? a. Functional ability and emotional status b. Chronological age and sexual function c. Economic status and sources of income d. Developmental history, interests, and activities ANS: A Information related to functional ability and emotional status provides an overview of a patient‘s problems and abilities. It guides selection of interventions and services to meet identified needs. The distracters reflect information of relevance, but are not of highest priority. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Pages 31-12, 20 TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 5. A 75-year-old patient comes to the clinic reporting frequent headaches. As the nurse begins the interaction, which action is most important? a. Complete a neurological assessment. b. Determine whether the patient can hear as the nurse speaks. c. Suggest that the patient lie down in a darkened room for a few minutes. d. Administer medication to relieve the patient‘s pain before continuing the assessment. ANS: B Before proceeding with any further assessment, the nurse should assess the patient‘s ability to hear questions. Impaired hearing could lead to inaccurate answers. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) REF: Pages 31-3, 18, 43 (Box 31-6) TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 6. Which statement about aging provides the best rationale for focused assessment of elderly patients? a. The elderly are usually socially isolated and lonely. testbanks_and_xanax b. Vision, hearing, touch, taste, and smell decline with age. c. The majority of elderly patients have some form of early dementia. d. As people age, thinking becomes more rigid and learning is impaired. ANS: B Only the key is a true statement. It cues the nurse to assess sensory function in the elderly patient. Correcting vision and hearing are critical to providing safe care. The distracters are myths about aging. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Pages 31-3, 18, 43 (Box 31-6) TOP: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance 7. A nurse assesses an elderly patient. The nurse should complete the Geriatric Depression Scale if the patient answers which question affirmatively. a. ―Would you say your mood is often sad?‖ b. ―Are you having any trouble with your memory?‖ c. ―Have you noticed an increase in your alcohol use?‖ d. ―Do you often experience moderate to severe pain?‖ ANS: A Feeling low may be a symptom of depression. Low moods occurring with regularity should signal the need for further assessment for other symptoms of depression. The other options do not focus on mood. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Pages 31-3, 44 (Box 31-7) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity 8. A health care provider writes these new prescriptions for a resident in a skilled nursing facility: 2 g sodium diet, restraint as needed, limit fluids to 1800 mL daily, continue antihypertensive medication, milk of magnesia 30 mL PO once if no bowel movement for 3 days. The nurse should a. question the fluid restriction. b. question the order for restraint. c. transcribe the prescriptions as written. d. assess the resident‘s bowel elimination. ANS: B Restraints may be imposed only on a written order of the health care provider that specifies the duration during which the restraints can be used. The Joint Commission guidelines and Omnibus Budget Reconciliation Act regulations also mandate a number of other conditions that must be considered and documented before restraints are used. The other prescriptions are appropriate. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 31-25 TOP: Nursing Process: Implementation MSC: Client Needs: Safe, Effective Care Environment testbanks_and_xanax 9. An elderly patient must be physically restrained. Who is responsible for the patient‘s safety? a. The nurse assigned to care for the patient b. Unlicensed assistive personnel who apply the restraint c. Family member who agrees to application of the restraint d. Health care provider who prescribed application of restraint ANS: A Although restraint is prescribed by a health care provider, the restraint is a measure carried out by nursing staff. The nurse caring for the patient is responsible for safe application of restraining devices and for providing safe care while the patient is restrained. Nurses may delegate the application of restraining devices and the care of the patient in restraint, but the nurse remains responsible for outcomes. Even when family agree to restraint, nurses are responsible for providing safe outcomes. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 31- 25 TOP: Nursing Process: Implementation MSC: Client Needs: Safe, Effective Care Environment 10. A new nurse asks, ―My elderly patient‘s CT scan of the head shows many Lewy bodies are present. What should I do about assessing for pain?‖ Select the best response from the nurse manager. a. ―Ask the patient‘s family if they think the patient is experiencing pain.‖ b. ―Use a visual analog scale to help the patient determine the presence and severity of pain.‖ c. ―There are special scales for assessing patients with dementia. Let‘s review how to use them.‖ d. ―The perception of pain is diminished by this type of dementia. Focus your assessment on the patient‘s mental status.‖ ANS: C Lewy bodies associated with dementia [Faculty note: Lewy bodies are defined and addressed in Chapter 23]. There are special scales to assess the presence and severity of pain in patients with dementia. The Pain Assessment in Advanced Dementia Scale evaluates breathing, negative vocalizations, body language, and consolability. A patient with dementia would be unable to use a visual analog scale. The family may be able to help the nurse gain perspective about the pain, but this strategy alone is inadequate. The other distracters are myths. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) REF: Pages 31-9, 10, 34 (Figure 31-4) | Page 31-37 (Box 31-2) TOP: Nursing Process: Assessment MSC: Client Needs: Safe, Effective Care Environment 11. An advance directive gives legally binding direction for health care interventions when a patient a. has a new diagnosis of cancer. b. is diagnosed with Parkinson‘s disease. c. is unable to make decisions for self because of illness. d. diagnosed with amyotrophic lateral sclerosis is unable to speak. testbanks_and_xanax ANS: C Advance directives are invoked when patients are unable to make their own health care decisions. The correct response is the most global answer. A diagnosis of cancer or Parkinson‘s disease does not mean the patient is unable to make a decision. For a patient with amyotrophic lateral sclerosis, there are other ways to communicate beyond speaking. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Pages 31-14, 15 TOP: Nursing Process: Planning MSC: Client Needs: Safe, Effective Care Environment [Show More]

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