The nurse is completing an assessment on an older-adult patient who is having difficulty falling asleep. Which condition will the nurse further assess for in this patient?
Depression
Muscle fatigue
Hypertension
Hypothyroidism
The Correct Answer is A
Choice A reason: Depression is strongly linked to insomnia in older adults, causing difficulty falling asleep due to rumination, low mood, or altered sleep architecture. Assessing for depression is critical, as it may underlie the sleep disturbance, requiring targeted interventions like therapy or antidepressants to improve sleep and mental health.
Choice B reason: Muscle fatigue may cause physical discomfort but is not a primary cause of difficulty falling asleep. It is more likely to affect sleep quality than initiation. Depression is a more common and significant contributor to insomnia in older adults, making this an incorrect choice.
Choice C reason: Hypertension can be associated with sleep apnea but is not directly linked to difficulty falling asleep. It may result from poor sleep but is less likely the cause. Depression is a more prevalent cause of insomnia, making this a less relevant condition to assess.
Choice D reason: Hypothyroidism can cause fatigue and sleepiness, not difficulty falling asleep. It is less commonly associated with insomnia compared to depression, which significantly disrupts sleep onset in older adults. This condition is less relevant to the patient’s presentation, making it incorrect.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Self-care deficit addresses physical inability to perform daily tasks, not psychological issues from sensory impairments. Hearing and visual loss primarily impact communication, leading to socialization issues. Assuming self-care deficit misaligns the diagnosis, risking neglect of psychological needs like social isolation, critical for mental health in sensory-impaired patients.
Choice B reason: Risk for falls is a physical safety concern due to sensory impairments but not psychological. Impaired socialization better addresses the psychological impact of communication barriers. Prioritizing falls risks overlooking social isolation, delaying interventions like communication aids, essential for mental well-being in patients with hearing and visual deficits.
Choice C reason: Impaired socialization, a psychological nursing diagnosis, reflects the communication barriers from hearing and visual impairments, leading to social isolation and emotional distress. This diagnosis guides interventions like assistive devices or support groups, critical for mental health, ensuring patients maintain social connections and emotional resilience despite sensory challenges.
Choice D reason: Impaired physical mobility relates to movement limitations, not psychological effects of sensory impairments. Hearing and visual loss primarily cause socialization issues, not mobility deficits. Assuming mobility misdirects care, neglecting psychological needs like social engagement, critical for preventing isolation and supporting mental health in sensory-impaired patients.
Correct Answer is B
Explanation
Choice A reason: Family relocation can cause stress or adjustment issues but is not a primary driver of developmental problems. It may temporarily affect social or academic progress, but its impact is less consistent than prolonged poverty, which has broader, long-term effects on development, making this an incorrect choice.
Choice B reason: Prolonged poverty is strongly linked to developmental problems, as it limits access to nutrition, healthcare, and education, impacting cognitive, physical, and emotional growth. Chronic socioeconomic stress can lead to developmental delays or behavioral issues, making this a critical sociocultural finding for the nurse to assess.
Choice C reason: Childhood obesity may indicate health issues like poor diet or inactivity, but its link to developmental problems is less direct than poverty. It can affect self-esteem or physical mobility but is not a primary sociocultural driver of broad developmental delays, making this a less critical finding.
Choice D reason: Loss of stamina is a vague symptom, often age-related or due to medical conditions, not a sociocultural factor. It does not directly indicate developmental problems, especially Dalin children, where poverty has a stronger impact on growth and milestones, making this an incorrect choice.
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