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

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A reason: Asking the family about normal behavior provides subjective context but lacks standardized cognitive assessment. Cognitive function requires objective tools like the MMSE to evaluate memory, orientation, and attention. Relying solely on family input risks missing subtle deficits, delaying diagnosis of conditions like dementia or delirium critical for patient management.

Choice B reason: Asking for name, location, and month tests orientation, a component of cognitive assessment, but is too limited. The MMSE offers a comprehensive evaluation of memory, language, and visuospatial skills. This narrow approach risks overlooking broader cognitive impairments, potentially missing early dementia or other neurological conditions requiring targeted interventions.

Choice C reason: The HHIE-S assesses hearing impairment, not cognitive function. Hearing loss may affect communication but isn’t a direct cognitive measure. Using this tool for cognition misdirects assessment, risking failure to identify cognitive deficits like memory loss, delaying diagnosis and management of conditions such as Alzheimer’s disease or acute confusional states.

Choice D reason: Administering the MMSE is a standardized, comprehensive tool to assess cognitive function, evaluating orientation, memory, attention, language, and visuospatial skills. It detects impairments in conditions like dementia or delirium, guiding diagnosis and treatment. Its structured approach ensures reliable identification of cognitive deficits, critical for planning care and interventions in clinical settings.

A. Maintaining belief. B. Instilling faith-hope. C. Maintaining ethics. D. Instilling values.

Correct Answer is B

Explanation

Choice A reason: Maintaining belief, while part of Watson’s model, focuses on sustaining patient values, not directly fostering hope. Instilling faith-hope is a specific carative factor addressing spiritual and emotional needs, more relevant for holistic care. Prioritizing belief risks underemphasizing hope’s role in motivating patients, especially in challenging health scenarios requiring emotional resilience.

Choice B reason: Instilling faith-hope, a core carative factor in Watson’s caring theory, involves fostering optimism and spiritual strength, enhancing patient coping and resilience. This promotes holistic healing by addressing emotional and existential needs, critical in serious illness or recovery, encouraging patients to find meaning and hope, improving psychological and physical outcomes.

Choice C reason: Maintaining ethics is not a specific carative factor in Watson’s model, though ethical care is implicit. Instilling faith-hope directly supports patients’ emotional and spiritual needs, central to holistic nursing. Focusing on ethics risks missing Watson’s emphasis on caring processes like hope, which enhance patient trust and healing in clinical practice.

Choice D reason: Instilling values is not a carative factor in Watson’s model, which emphasizes factors like faith-hope for holistic care. Values are patient-specific and not nurse-instilled. Prioritizing this misaligns with Watson’s framework, potentially neglecting emotional support like hope, critical for fostering patient resilience and well-being in health challenges.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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