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

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A reason:
The statement "Repeat the dose in 15 minutes if the client is still anxious" is not appropriate. Lorazepam is a benzodiazepine that can cause significant sedation and central nervous system depression. Repeating the dose too soon can increase the risk of severe sedation, respiratory depression, and other adverse effects.

Choice B reason:
The statement "Initiate fall precautions for the client" is the correct response. Lorazepam can cause dizziness, drowsiness, and impaired coordination, increasing the risk of falls, especially in older adults. Implementing fall precautions is essential to ensure the client's safety.

Choice C reason:
The statement "Instruct the client to expect ringing in the ears" is incorrect. Tinnitus (ringing in the ears) is not a common side effect of lorazepam. Common side effects include drowsiness, dizziness, and muscle weakness.

Choice D reason:
The statement "Place the client in restraints for 1 hour" is inappropriate. Restraints should only be used as a last resort when the client poses a danger to themselves or others and when less restrictive measures have failed.

A. Discuss adverse effects of antianxiety medications with a client who has an anxiety disorder. B. Participate in solitary activities with a client who has mania. C. Explain the benefits of light therapy to a client who has a depressive disorder. D. Witness an informed consent for a client who is scheduled for electroconvulsive therapy.

Correct Answer is B

Explanation

Choice A reason:
The statement "Discuss adverse effects of antianxiety medications with a client who has an anxiety disorder" is not appropriate for delegation to assistive personnel. Discussing medication effects requires specialized knowledge and the ability to provide detailed explanations and answer questions, which falls within the scope of practice for licensed nurses or healthcare providers.

Choice B reason:
The statement "Participate in solitary activities with a client who has mania" is the correct response. Assistive personnel can engage clients in activities that do not require specialized medical knowledge or judgment. Participating in solitary activities can help manage the client's symptoms and provide therapeutic engagement.

Choice C reason:
The statement "Explain the benefits of light therapy to a client who has a depressive disorder" is not suitable for delegation to assistive personnel. Explaining treatment benefits and answering related questions requires a deeper understanding of the therapy and its implications, which is within the scope of practice for licensed nurses or healthcare providers.

Choice D reason:
The statement "Witness an informed consent for a client who is scheduled for electroconvulsive therapy" is not appropriate for delegation to assistive personnel. Witnessing informed consent involves ensuring that the client fully understands the procedure, its risks, and benefits, which requires professional judgment and is typically performed by licensed nurses or healthcare providers.

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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?

Nursing Test Bank

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