GERONTOLOGY FINAL EXAM PRACTICE STUDY GUIDE

A community health nurse is assessing an older adult client who lives alone. The nurse finds that, although the client is able to answer all questions appropriately, the client has a decreased attention span, expresses feelings of overwhelming sadness, and has a low energy level. The nurse should identify that the client is exhibiting manifestations of which of the following disorders? a. Delusions b. Dementia c. Delirium d. Depression - Depression *RATIONALE* The client who has an inability to sleep or complete ADLs is exhibiting manifestations of depression. Depression involves a cluster of manifestations that include changes in sleep habits, appetite, and relationships with others. Clients who have depression might have a decreased ability to make decisions or concentrate and, in some cases, complete ADLs. Anhedonia, the inability to feel happy, is another manifestation of depression. *FYI* A client who has false personal beliefs despite evidence to the contrary is exhibiting manifestations of delusions ... A client who has severe memory loss and an inability to solve problems is exhibiting manifestations of dementia ... A client who has a sudden onset of confusion, disorientation, altered level of consciousness, and an inability to focus is exhibiting manifestations of delirium. A community health nurse is visiting the home of an older adult client and her caregiver. The client has excoriations to her wrists and ankles. Which of the following actions should the nurse take first? a. Refer the caregiver to a support group. b. Interview the client in private. c. Document the client's wounds. d. Contact adult protective services. - Interview the client in private. *RATIONALE* The nurse should apply the nursing process priority-setting framework. The nurse can use the nursing process to plan client care and prioritize nursing actions. Each step of the nursing process builds upon the previous step, beginning with assessment or data collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify the provider of a change in the client's status,