George Palo VSIM
Which assessment findings would indicate that Mr. Palo is experiencing both insufficient
nutritional and fluid intake? (Select all that apply.) - ✔️✔️General weakness
Altered mental status
Weight loss
Poor skin turgor
Rationale: Indications of poor nutritional and fluid intake would include all the options
with the exception of bradycardia. Such deficiencies would result in tachycardia and
hypotension.
When assessing Mr. Palo's risk for acute depression, the nurse is using the Geriatric
Depression Scale: Short Form. What question(s) should the nurse be prepared to ask
Mr. Palo? (Select all that apply.) - ✔️✔️"Are you basically satisfied with your life?"
"Do you often get bored?"
"Do you feel pretty worthless the way you are now?"
Rationale: This depression screening tool focuses on older patients' feelings and the
possible presence of boredom, worthlessness, and satisfaction with their current life.
The origin or specific circumstances associated with their feelings are not addressed by
the screening's short form.
When Mr. Palo is unable to button his shirt appropriately after numerous attempts, the
nurse matter-of-factly resumes the task for hm. What is the primary rationale for the
nurse's actions? - ✔️✔️Minimizes his frustration with his failure to complete the task.
Rationale: The nurse is correct in using a matter-of-fact approach when assuming tasks
the patient can no longer perform. Preventing patients from working unsuccessfully at a
task for an extended time helps in preserving their dignity and minimizing their
frustration with their progressive memory loss. Although the nurse's action does help
achieve the other options, none of them is the primary reason for the intervention.
Mr Palo is demonstrating a rather pessimistic attitude when he and the nurse discuss
ways to minimize his tendency to socially isolate. Which technique should the nurse
implement to help him take a positive role in this discussion? - ✔️✔️Encouraging Mr.
Palo to identify ways he could volunteer his time caring for animals.
Rationale: The nurse should use therapeutic techniques to encourage patients to
generate their own solutions. Studies have shown that patients tend to act on plans or
solutions they generate rather than those that others offer. Finding and acting on their
own solutions gives patients a renewed sense of competence and self-worth. All the
other options provide possible solutions for his issue with socializtion.
, Considering Mr. Palo's history and assessment findings, which factor is most likely the
primary contributor to the recent weight loss? - ✔️✔️Depression
Rationale: A commonly observed physical response to depression is poor appetite and
the resulting weight loss. Although nausea and vomiting are possible side effects of
galantamine, there are no assessment data to suggest the patient is experiencing
either. Both living alone and dementia (including Alzheimner disease), especially in its
later stages can affect the patient's interest in preparing and eating food, but neigher
has the high degree of influence presented by depression.
Which statement made by Mr. Palo would demonstrate that his religious belief system is
influential in the decision not to consider suicide? - ✔️✔️"No! He gives it and only He
can take it away."
Rationale: Suicidal thoughts are common in people with mood disorders, especially
depression. An individual's belief systems and values can influence his or her decision
concerning the act of suicide. Mr. Palo's reference to his belief in the time of death being
determined only by God supports the religious influence of his decision. The other
statements express various ethical objections to suicide but do not indicate that they are
based on his religious belief system.
Which nursing interventions implemented during Mr. Palo's assessment will assist him
to communicate as effectively as his cognitive deterioration allows? (Select all that
apply.) - ✔️✔️Providing simple explanations about why questions are being asked
Phrasing questions so as to require simple answers
Arranging for frequent breaks in the assessment process
Allowing ample time for the patient to respond to questions.
Rationale: The nurse provides simple explanations as often as patients need them,
such as "I'm asking these questions so the staff can see how your health is." It helps to
ask simple questions (those that require simple answers) rather than compound
questions, and to allow patients ample time to answer. Patients may become confused
or tire easily, so frequent breaks in the interview may be needed, Although it might
become necessary to rely on family for answers to assessment questions, Mr. Palo
appears capable of being the primary information provider. Relying on his daughter at
this point would be nontherapeutic because it would minimize his role in the assessment
process.
Which statement made by Mr. Palo identifies an intervention that his family has
implemented to help deal with his decline in executive functioning? - ✔️✔️"I put my
bills in a special box, and Maggie pays them twice a month."
Rationale: Having difficulty paying one's bills on time and correctly would be an example
of a disturbance in executive functioning, which is the ability to think abstractly and to
Which assessment findings would indicate that Mr. Palo is experiencing both insufficient
nutritional and fluid intake? (Select all that apply.) - ✔️✔️General weakness
Altered mental status
Weight loss
Poor skin turgor
Rationale: Indications of poor nutritional and fluid intake would include all the options
with the exception of bradycardia. Such deficiencies would result in tachycardia and
hypotension.
When assessing Mr. Palo's risk for acute depression, the nurse is using the Geriatric
Depression Scale: Short Form. What question(s) should the nurse be prepared to ask
Mr. Palo? (Select all that apply.) - ✔️✔️"Are you basically satisfied with your life?"
"Do you often get bored?"
"Do you feel pretty worthless the way you are now?"
Rationale: This depression screening tool focuses on older patients' feelings and the
possible presence of boredom, worthlessness, and satisfaction with their current life.
The origin or specific circumstances associated with their feelings are not addressed by
the screening's short form.
When Mr. Palo is unable to button his shirt appropriately after numerous attempts, the
nurse matter-of-factly resumes the task for hm. What is the primary rationale for the
nurse's actions? - ✔️✔️Minimizes his frustration with his failure to complete the task.
Rationale: The nurse is correct in using a matter-of-fact approach when assuming tasks
the patient can no longer perform. Preventing patients from working unsuccessfully at a
task for an extended time helps in preserving their dignity and minimizing their
frustration with their progressive memory loss. Although the nurse's action does help
achieve the other options, none of them is the primary reason for the intervention.
Mr Palo is demonstrating a rather pessimistic attitude when he and the nurse discuss
ways to minimize his tendency to socially isolate. Which technique should the nurse
implement to help him take a positive role in this discussion? - ✔️✔️Encouraging Mr.
Palo to identify ways he could volunteer his time caring for animals.
Rationale: The nurse should use therapeutic techniques to encourage patients to
generate their own solutions. Studies have shown that patients tend to act on plans or
solutions they generate rather than those that others offer. Finding and acting on their
own solutions gives patients a renewed sense of competence and self-worth. All the
other options provide possible solutions for his issue with socializtion.
, Considering Mr. Palo's history and assessment findings, which factor is most likely the
primary contributor to the recent weight loss? - ✔️✔️Depression
Rationale: A commonly observed physical response to depression is poor appetite and
the resulting weight loss. Although nausea and vomiting are possible side effects of
galantamine, there are no assessment data to suggest the patient is experiencing
either. Both living alone and dementia (including Alzheimner disease), especially in its
later stages can affect the patient's interest in preparing and eating food, but neigher
has the high degree of influence presented by depression.
Which statement made by Mr. Palo would demonstrate that his religious belief system is
influential in the decision not to consider suicide? - ✔️✔️"No! He gives it and only He
can take it away."
Rationale: Suicidal thoughts are common in people with mood disorders, especially
depression. An individual's belief systems and values can influence his or her decision
concerning the act of suicide. Mr. Palo's reference to his belief in the time of death being
determined only by God supports the religious influence of his decision. The other
statements express various ethical objections to suicide but do not indicate that they are
based on his religious belief system.
Which nursing interventions implemented during Mr. Palo's assessment will assist him
to communicate as effectively as his cognitive deterioration allows? (Select all that
apply.) - ✔️✔️Providing simple explanations about why questions are being asked
Phrasing questions so as to require simple answers
Arranging for frequent breaks in the assessment process
Allowing ample time for the patient to respond to questions.
Rationale: The nurse provides simple explanations as often as patients need them,
such as "I'm asking these questions so the staff can see how your health is." It helps to
ask simple questions (those that require simple answers) rather than compound
questions, and to allow patients ample time to answer. Patients may become confused
or tire easily, so frequent breaks in the interview may be needed, Although it might
become necessary to rely on family for answers to assessment questions, Mr. Palo
appears capable of being the primary information provider. Relying on his daughter at
this point would be nontherapeutic because it would minimize his role in the assessment
process.
Which statement made by Mr. Palo identifies an intervention that his family has
implemented to help deal with his decline in executive functioning? - ✔️✔️"I put my
bills in a special box, and Maggie pays them twice a month."
Rationale: Having difficulty paying one's bills on time and correctly would be an example
of a disturbance in executive functioning, which is the ability to think abstractly and to
