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: A belief tool is not a standardized method for spiritual assessment. The FICA tool specifically evaluates faith, importance, community, and action, including questions about God and purpose. Assuming a vague belief tool risks incomplete assessment, missing critical spiritual needs that influence patient coping and well-being in holistic care settings.
Choice B reason: The spiritual well-being scale measures general spiritual health but is not structured for detailed questions about God or life purpose, unlike the FICA tool’s targeted approach. Using this risks missing specific spiritual concerns, limiting the nurse’s ability to address existential needs critical for patient support in illness or end-of-life care.
Choice C reason: The FICA assessment tool (Faith, Importance, Community, Action) involves structured questions to evaluate spiritual beliefs, including relationships with God and life purpose. Its comprehensive 20-question format assesses spiritual needs, guiding holistic care. This method ensures tailored interventions, supporting emotional and spiritual well-being, critical for patients facing serious health challenges.
Choice D reason: The hope scale measures optimism but not specifically the relationship with God or life purpose, unlike the FICA tool’s broader spiritual focus. Assuming this method risks overlooking religious or existential concerns, reducing the effectiveness of spiritual care in addressing patient needs for meaning and satisfaction during health crises.
Correct Answer is D
Explanation
Choice A reason: Culture and ethnicity influence pain perception but are not easily modifiable. They shape attitudes toward pain expression, not pain itself. Focusing on these risks overlooking modifiable factors like anxiety, which directly amplify pain. Interventions targeting modifiable psychological factors are more effective in reducing pain intensity and improving patient coping strategies.
Choice B reason: Previous pain experiences and cognitive abilities are relatively fixed, shaping pain perception but not easily altered. Modifiable factors like anxiety have a greater immediate impact on pain. Focusing on these risks delaying interventions like relaxation techniques, which directly reduce pain amplification, improving outcomes in acute or chronic pain management.
Choice C reason: Age and gender are non-modifiable factors influencing pain sensitivity but not amenable to change. Anxiety and fear, which exacerbate pain through stress responses, are modifiable and more relevant for intervention. Prioritizing age or gender misdirects focus, delaying strategies like cognitive therapy that effectively mitigate pain in clinical settings.
Choice D reason: Anxiety and fear are modifiable factors that amplify pain via heightened stress responses, increasing muscle tension and pain perception. Interventions like relaxation, mindfulness, or counseling can reduce these, lowering pain intensity. Focusing on these targets psychological contributors, improving pain management and patient comfort, especially in acute or chronic pain scenarios.
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