An older adult client who has been talking to the client's deceased mother is referred to the psychiatric clinic for an evaluation. Which assessment should the nurse complete first?

Assess daily alcohol intake.

Identify signs of depression.

Determine cognitive status.

Review risk factors for abuse.

Answer and Explanation

The Correct Answer is C

A. Assess daily alcohol intake: Alcohol misuse can contribute to a variety of psychiatric symptoms, including hallucinations or delusions. Older adults may metabolize alcohol differently, leading to higher susceptibility to its effects. While this is important, it may not be the first priority unless there are clear signs of alcohol misuse (e.g., smell of alcohol, history provided by the client or family).

B. Identify signs of depression: Depression in older adults can sometimes present with psychotic features, including hallucinations or delusions. Understanding the client's emotional state and identifying symptoms of depression can provide insight into the cause of their behaviour. Depression is common in older adults and can be a precursor or a component of other psychiatric conditions.

C. Determine cognitive status: Cognitive impairment (e.g., dementia) can often present with hallucinations or delusions, and evaluating cognitive status can help differentiate between different types of disorders (e.g., dementia vs. primary psychotic disorders). Assessing cognitive function helps in identifying conditions like Alzheimer's disease or other dementias where hallucinations can be a symptom. This assessment can guide the further direction of evaluation and treatment, making it a critical first step.

D. Review risk factors for abuse: Older adults are at risk of abuse, which can include physical, emotional, and financial abuse. Identifying these risk factors is crucial for their safety and well-being. While this is a significant concern, unless there are immediate signs or disclosures of abuse, it may not be the most urgent assessment in the context of hallucinations.

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Correct Answer is B

Explanation

A. Auscultate the lymph node for the presence of a bruit.

Auscultating for a bruit over a lymph node may not be the most immediate or relevant action in this situation. While it could provide additional information about blood flow, it may not necessarily explain the cause of the enlarged lymph node.

B. Ask the client about any localized tenderness at the site.

This is an appropriate action. Localized tenderness at the site of an enlarged lymph node could indicate inflammation or infection. Gathering information about tenderness can help in understanding the possible cause of the lymphadenopathy.

C. Cover the inflamed area and notify the healthcare provider.

This is a reasonable action. Covering the inflamed area can help protect it from further irritation or infection. Notifying the healthcare provider is important because they can assess the lymph node, gather additional history, and determine if further evaluation or treatment is necessary.

D. Record this normal finding in the assessment record.

This option is incorrect. An enlarged, visible lymph node is not considered a normal finding. It could indicate underlying infection, inflammation, or another health issue. Recording it as a normal finding could lead to overlooking potential health concerns.

A. Decreased BP during orthostatic blood pressure measurement. B. Grade 3 systolic murmur auscultated at the pulmonic site. C. 3+ carotid pulse volume bilaterally. D. Positive jugular vein distention (JVD) bilaterally.

Correct Answer is A

Explanation

A. Decreased BP during orthostatic blood pressure measurement: Syncope (fainting) often results from decreased blood flow to the brain. Orthostatic hypotension (a drop in blood pressure upon standing) can lead to syncope.

B. Grade 3 systolic murmur auscultated at the pulmonic site: A systolic murmur may indicate valvular or cardiac issues but is not directly related to syncope.

C. 3+ carotid pulse volume bilaterally: Carotid pulse volume assessment helps evaluate blood flow to the brain. Normal carotid pulses are important for preventing syncope

D. Positive jugular vein distention (JVD) bilaterally: JVD is associated with heart failure or fluid overload. While it may not directly cause syncope, it can contribute to overall cardiovascular instability.

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An older adult client who has been talking to the client's deceased mother is referred to the psychiatric clinic for an evaluation. Which assessment should the nurse complete first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse notes an enlarged, visible lymph node on the client's neck. Which action should the nurse take next?

Correct Answer is B

Explanation

A client reports episodes of syncope. Which assessment finding should the nurse anticipate?

Correct Answer is A

Explanation

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