Chapter 38: Mental Health Assessment of Older Adults

Format: Multiple Choice

Client Needs: Health Promotion and Maintenance

Cognitive Level: Apply

Integrated Process: Nursing Process

Objective: 2

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1. A nurse is caring for a 76-year-old client with a hearing deficit caused by presbycusis. Which action would be most appropriate for the nurse to take when communicating with the client?

A) Use a higher volume of speech.

B) Address the client’s family members.

C) Ask if the client can use sign language.

D) Use lower-pitched tones.

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2. The nurse is caring for a 78-year-old client who is taking a medication with anticholinergic properties. The client reports dry mouth. Which suggestion is most appropriate?

A) Chew sugared hard candies.

B) Rinse the mouth with an alcohol-free mouthwash.

C) Use more seasonings on food.

D) Drink decaffeinated beverages often.

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3. An elderly client who has been constipated for the last few days tells the nurse about the decision to use an over-the-counter fiber laxative that is dissolved in water. When reviewing the use of this laxative with the client, which information would the nurse include as a possible side effect?

A) Diarrhea

B) Nausea

C) Flatus

D) Stomach pain

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4. An 80-year-old client visits the mental health clinic. During the assessment process, the client tells the nurse, “I’m 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?”

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5. While caring for an 88-year-old client suspected of having dementia, the nurse assesses the client for a common delusional thought. Which client statement 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.”

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6. A nurse is assessing a 78-year-old client who lives in a home alone. To assess the client’s 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?”

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7. The nurse is assessing a client with a history of heavy drinking who lost a spouse to cancer last year. The client reports receiving less sleep than when the client 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?”

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8. An adult is concerned that a parent may be developing depression. In questioning the adult, which statement would support the concern?

A) “Dad has been crying off and on now for over two weeks since Mom died. He’s also still having trouble sleeping.”

B) “Dad is agitated and anxious; he’s been that way for a month now since Mom died.”

C) “It’s been over three months since Mom died, and Dad keeps crying; he can’t eat or sleep.”

D) “Mom’s funeral was last week, and Dad hasn’t been able to eat or sleep since then.”

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9. A nurse is providing an in-service educational program for beginning nurses regarding mental health assessment needs of older adults. 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 than the client if the client has memory impairment. The nurse also emphasizes that interviewing family members provides which additional assessment finding?

A) A more accurate picture of the social support resources available

B) Evaluation of the family’s ability to effectively care for the older client

C) Determination of the extent of the client’s memory impairment

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

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10. Assessment of an older adult diagnosed with dementia with Lewy bodies reveals that the client is receiving psychiatric medications. The client states, “I get dizzy periodically and have trouble walking.” Which action should the nurse take first?

A) Assess for development of orthostatic hypotension.

B) Instruct the client to stop taking the psychiatric medications.

C) Interview the client’s family about the client’s coping skills and current stress level.

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

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11. A nurse is preparing a presentation for a group of colleagues about suicide and the older adult population. Which finding would the nurse include in this presentation?

A) Suicide is less of a risk in this population 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.

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12. A group of nursing students is reviewing information about age-related changes occurring in cognition and intellectual performance. The students demonstrate understanding of the concepts when they identify which cognitive change for a client diagnosed with delirium?

A) Orientation to time

B) Inability to recognize familiar objects

C) Diminished executive functioning

D) Restricted judgment

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13. 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) 1

B) 3

C) 7

D) 13

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14. A nurse suspects an older adult client is experiencing depression. Which finding can be obtained from the nutritional assessment of the client would support the nurse’s suspicion?

A) Weight loss of 12 pounds

B) Increased caloric intake

C) Cravings for sugar rich foods

D) Becoming a vegetarian

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15. The nurse is conducting a risk assessment with an older adult client. Which finding would be most concerning regarding the risk for suicide?

A) Depression

B) Cognitive impairment

C) Memory changes

D) Mania

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16. The nurse is caring for an older client who was brought to the emergency department by a daughter after she noted a change in the client’s behavior over the past two days. The client has no history of a mental illness, yet the daughter describes the client as being confused after having a fall at home. When assessing the client’s biological domain, which data is critical in identifying the underlying cause of the client’s condition?

A) The client spent a day outside in high temperatures.

B) The client’s brother has schizophrenia.

C) The client lives in the community alone.

D) The client drinks one glass of wine each evening.

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17. The nurse is assessing an older adult client with a diagnosis of dementia who states, “There is someone in my house pretending to be my spouse.” The client’s spouse is attending the assessment and tells the nurse that this is not actually true. Which assessment tool should the nurse use to further assess this client?

A) Neuropsychiatric Inventory

B) Geriatric Depression Scale

C) Instrumental Activities of Daily Living Scale

D) Index of Independence in Activities of Daily Living

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

A) Apprehension

B) Motor tension

C) Life satisfaction

D) Boredom

E) Autonomic hyperactivity

F) Worry

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19. 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 area would the nurse assess? Select all that apply.

A) Dysphoria

B) Inhibition

C) Apathy

D) Level of orientation

E) Memory

F) Anxiety

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20. The nurse is assessing an older adult client who tells the nurse, “I feel hopeless.” The nurse should consider referring the client for more intense monitoring if which risk factors are identified? Select all that apply.

A) Recently experienced the death of a pet

B) Attempted suicide by overdose 5 years ago

C) Lives with limited finances

D) Does not enjoy the company of others

E) Buys groceries for extended family members