The patient describes loss of significant others, economic security, and health. He describes mood alteration and voices the thought that he has little to live for. Combined with his age, sex, and single status, each is a risk factor for suicide. Elderly white males have the highest risk for completed suicide. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Pages 31-3 to 5, 8 (Evidence Based Practice) TOP: Nursing Process: Analysis/Diagnosis MSC: Client Needs: Psychosocial Integrity 15. In a sad voice, an elderly patient tells the nurse of the recent deaths of a spouse and close
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friend. The patient has no other family and only a few acquaintances in the community. The nurse’s priority is to determine whether which nursing diagnosis applies to this patient? a. Risk for suicide related to recent deaths of significant others b. Anxiety related to sudden and abrupt lifestyle changes c. Social isolation related to loss of existing family d. Spiritual distress related to anger with God ANS: A
_a
nd
The patient appears to be experiencing normal grief related to the loss of her family, but because of age and social isolation, the risk for suicide should be determined and has high priority. No defining characteristics exist for the diagnoses of anxiety or spiritual distress. The patient’s social isolation is important, but the risk for suicide has higher priority.
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PTS: 1 DIF: Cognitive Level: Analyze (Analysis) REF: Pages 31-3 to 5, 8 (Evidence Based Practice) TOP: Nursing Process: Analysis/Diagnosis MSC: Client Needs: Psychosocial Integrity 16. When making a distinction as to whether an elderly patient has confusion related to delirium
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ANS: C
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or another problem, what information would be of particular value? a. Evidence of spasticity or flaccidity b. The patient’s level of motor activity c. Medications the patient has recently taken d. Level of preoccupation with somatic symptoms
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Delirium in the elderly produces symptoms of confusion. Medication interactions or adverse reactions are often a cause. The distracters do not give information important for delirium.
eB
PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Pages 31-3, 4, 6 TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
17. An 85-year-old has difficulty walking after a knee replacement. The patient tells the nurse,
“It’s awful to be old. Every day is a struggle. No one cares about old people.” Select the nurse’s best response. a. “Everyone here cares about old people. That’s why we work here.” b. “It sounds like you’re having a difficult time. Tell me about it.” c. “Let’s not focus on the negative. Tell me something good.” d. “You are still able to get around, and your mind is alert.”
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