A nurse is performing screening assessments for active older adult clients at a community clinic. Which of the following tests should the nurse include in the screening?
Geriatric Depression Scale
Pain Assessment in Advanced Dementia Scale
CAGE Questionnaire
Denver II Developmental Screening Test
The Correct Answer is A
Choice A reason:
The Geriatric Depression Scale (GDS) is a valuable tool for screening depression in older adults. Depression is common in this population and can significantly impact their quality of life. The GDS is specifically designed to identify symptoms of depression in the elderly, making it an essential part of the screening process for active older adults. The scale includes a series of questions that help determine the presence and severity of depressive symptoms. Early detection and treatment of depression can improve overall well-being and prevent further complications.
Choice B reason:
The Pain Assessment in Advanced Dementia (PAINAD) Scale is used to assess pain in individuals with advanced dementia who may not be able to communicate their pain verbally. While this tool is crucial for managing pain in dementia patients, it is not typically used for active older adults without dementia. The focus of the PAINAD Scale is on non-verbal cues and behaviors that indicate pain, which may not be relevant for the general active older adult population.
Choice C reason:
The CAGE Questionnaire is a screening tool for identifying potential alcohol abuse. It consists of four questions that help determine if an individual has issues with alcohol consumption. While alcohol abuse can be a concern in older adults, the CAGE Questionnaire is more specific to substance abuse rather than a general health screening for active older adults. It is important, but not as broadly applicable as the Geriatric Depression Scale for this context.
Choice D reason:
The Denver II Developmental Screening Test is designed to assess developmental progress in children from birth to six years old. It evaluates areas such as personal-social, fine motor-adaptive, language, and gross motor skills. This tool is not relevant for screening active older adults, as it is specifically tailored for identifying developmental delays in young children. Therefore, it would not be appropriate for use in a community clinic setting focused on older adults.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason:
Using short, simple sentences is an effective communication strategy for clients experiencing moderate anxiety. Anxiety can impair cognitive processing, making it difficult for clients to understand complex information. By using clear and concise language, the nurse can help the client better comprehend what to expect after the cardiac catheterization. This approach reduces the client's anxiety by providing information in a manageable format.
Choice B Reason:
Showing a 30-minute teaching video might be overwhelming for a client with moderate anxiety. While visual aids can be helpful, the length and complexity of the video could increase the client's anxiety rather than alleviate it. It is important to tailor the educational approach to the client's current emotional state, ensuring that the information is presented in a way that is easy to understand and not overwhelming.
Choice C Reason:
Providing detailed explanations can be counterproductive for a client with moderate anxiety. Detailed information might overwhelm the client, leading to increased anxiety and difficulty in processing the information. Instead, the nurse should focus on delivering key points in a clear and concise manner, ensuring that the client understands the most important aspects of the procedure and what to expect afterward.
Choice D Reason:
Avoiding questions is not an effective strategy for client education. Asking questions allows the nurse to assess the client's understanding and address any concerns or misconceptions. Engaging the client in a dialogue helps to build rapport and ensures that the client feels supported and informed. It is important to create an open and interactive environment where the client feels comfortable asking questions and expressing concerns.
Correct Answer is B
Explanation
Choice A reason:
The statement "Avoid asking direct questions about the client's experience" is not appropriate. It is important to understand the nature of the hallucinations to assess the client's condition accurately. Asking direct questions can help the nurse gather necessary information to provide appropriate care and interventions.
Choice B reason:
The statement "Focus the client on reality-based activities" is the correct response. Engaging the client in reality-based activities can help distract them from the hallucinations and reinforce their connection to the real world. This approach can reduce the intensity and frequency of hallucinations.
Choice C reason:
The statement "Convey sympathy for the client's experience" is not the most effective approach. While it is important to be empathetic, conveying sympathy without addressing the hallucinations can validate the client's distorted perceptions. Instead, the nurse should acknowledge the client's feelings and gently redirect them to reality-based activities.
Choice D reason:
The statement "Tell the client her experience is not real" is not advisable. Directly challenging the client's hallucinations can lead to increased agitation and mistrust. It is more effective to acknowledge the client's feelings and guide them towards reality-based activities.
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