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 A

Explanation

A. Cries vigorously when stimulated. A vigorous cry is a positive sign that the infant's lungs are functioning well and that they are receiving adequate oxygenation, indicating a good transition to extrauterine life.

B. Heart rate of 220 beats/minute. A heart rate of 220 beats/minute is too high for a newborn and could indicate tachycardia or distress, not a normal transition.

C. A positive Babinski reflex. A positive Babinski reflex is a normal finding in newborns but is not directly related to their immediate transition to extrauterine life. It is a neurological reflex that indicates normal nervous system function.

D. Flexion of all four extremities. Flexion of all four extremities is a good sign of normal muscle tone and neurological function but does not directly indicate respiratory or circulatory adaptation to extrauterine life as clearly as a vigorous cry does.

A. Eats less salt-cured meats. B. Participates in healing rituals. C. Uses herbal remedies. D. Meditates in sweat lodges.

Correct Answer is C

Explanation

A. Eats less salt-cured meats: Reducing the intake of salt-cured meats is generally a positive behaviour, especially for someone with hypertension. This behaviour aligns with dietary recommendations for managing high blood pressure.

B. Participates in healing rituals: Healing rituals are part of many cultural practices and can provide emotional and spiritual support. However, without further information, it's unclear if these rituals interfere with the prescribed treatment. This may warrant additional assessment to ensure they complement the medical regimen.

C. Uses herbal remedies: The use of herbal remedies could potentially interact with prescribed antihypertensive medications. This behaviour requires careful assessment to ensure there are no harmful interactions or adverse effects on the treatment plan.

D. Meditates in sweat lodges: Sweat lodges are a traditional practice for many Native Americans, providing physical and spiritual cleansing. However, the high temperatures and dehydration risks associated with sweat lodges could adversely affect blood pressure control and overall cardiovascular health. This behaviour requires further evaluation to ensure it is safe for the client with hypertension.

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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 is assessing a 38-week gestation newborn infant immediately following a vaginal birth. Which assessment finding best indicates that the infant is transitioning well to extrauterine life?

Correct Answer is A

Explanation

An older Native-American client with hypertension presents to an outpatient clinic for follow-up evaluation after initiation of treatment with oral antihypertensive medications. Report of which client behavior requires additional assessment by the nurse?

Correct Answer is C

Explanation

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