NUR255 Exam 4 V3 | Aging &
Mental Health Nursing Q&A with
Rationale | Galen College of
Nursing
1. An 82-year-old patient is admitted with a sudden onset of confusion and disorientation.
Which of the following conditions should the nurse prioritize for assessment?
A. Alzheimer’s Disease
B. Normal aging process
C. Delirium
D. Schizophrenia
Correct Answer: C
Expert Explanation: The sudden onset of confusion is a hallmark sign of delirium rather
than dementia. Delirium is often caused by underlying medical issues such as infections or
medication side effects. The nurse must identify and treat the root cause immediately to
prevent further complications.
2. Which assessment tool is most appropriate for a nurse to use when screening an older
adult for depression?
A. Mini-Mental State Examination (MMSE)
,B. Glasgow Coma Scale
C. Geriatric Depression Scale (GDS)
D. Branden Scale
Correct Answer: C
Expert Explanation: The Geriatric Depression Scale is specifically designed to screen for
depressive symptoms in the elderly population. It uses a simple format that avoids complex
questions which might be difficult for those with mild cognitive impairment. Accurate
screening is essential because depression in seniors is often misdiagnosed as dementia.
3. A client with moderate Alzheimer’s disease is experiencing ‘sundowning.’ Which
intervention should the nurse implement?
A. Increase caffeine intake in the late afternoon
B. Ensure the room is well-lit during late afternoon and evening
C. Provide a high-stimulation environment with loud music
D. Restrict fluid intake after 4:00 PM
Correct Answer: B
Expert Explanation: Sundowning refers to increased confusion and agitation that occurs
as daylight fades. Providing adequate lighting helps reduce shadows and visual
hallucinations that can trigger anxiety. Maintaining a calm environment and consistent
routine also helps minimize the severity of these episodes.
, 4. Which of the following is considered a primary risk factor for elder abuse?
A. Caregiver burnout and high stress levels
B. Financial independence of the elder
C. Strong social support networks
D. Living in an assisted living facility
Correct Answer: A
Expert Explanation: Caregiver stress is one of the most significant risk factors for the
development of elder abuse. When a caregiver is overwhelmed by the demands of an aging
relative, they may lash out physically or emotionally. Identifying these stressors early
allows for interventions such as respite care or support groups.
5. The nurse is caring for an older adult patient who is prescribed a new SSRI for depression.
Which side effect is of greatest concern in this population?
A. Increased appetite
B. Weight gain
C. Hyponatremia
D. Improved sleep patterns
Correct Answer: C
Expert Explanation: Older adults are at a higher risk for developing hyponatremia when
taking Selective Serotonin Reuptake Inhibitors (SSRIs). This condition occurs because
Mental Health Nursing Q&A with
Rationale | Galen College of
Nursing
1. An 82-year-old patient is admitted with a sudden onset of confusion and disorientation.
Which of the following conditions should the nurse prioritize for assessment?
A. Alzheimer’s Disease
B. Normal aging process
C. Delirium
D. Schizophrenia
Correct Answer: C
Expert Explanation: The sudden onset of confusion is a hallmark sign of delirium rather
than dementia. Delirium is often caused by underlying medical issues such as infections or
medication side effects. The nurse must identify and treat the root cause immediately to
prevent further complications.
2. Which assessment tool is most appropriate for a nurse to use when screening an older
adult for depression?
A. Mini-Mental State Examination (MMSE)
,B. Glasgow Coma Scale
C. Geriatric Depression Scale (GDS)
D. Branden Scale
Correct Answer: C
Expert Explanation: The Geriatric Depression Scale is specifically designed to screen for
depressive symptoms in the elderly population. It uses a simple format that avoids complex
questions which might be difficult for those with mild cognitive impairment. Accurate
screening is essential because depression in seniors is often misdiagnosed as dementia.
3. A client with moderate Alzheimer’s disease is experiencing ‘sundowning.’ Which
intervention should the nurse implement?
A. Increase caffeine intake in the late afternoon
B. Ensure the room is well-lit during late afternoon and evening
C. Provide a high-stimulation environment with loud music
D. Restrict fluid intake after 4:00 PM
Correct Answer: B
Expert Explanation: Sundowning refers to increased confusion and agitation that occurs
as daylight fades. Providing adequate lighting helps reduce shadows and visual
hallucinations that can trigger anxiety. Maintaining a calm environment and consistent
routine also helps minimize the severity of these episodes.
, 4. Which of the following is considered a primary risk factor for elder abuse?
A. Caregiver burnout and high stress levels
B. Financial independence of the elder
C. Strong social support networks
D. Living in an assisted living facility
Correct Answer: A
Expert Explanation: Caregiver stress is one of the most significant risk factors for the
development of elder abuse. When a caregiver is overwhelmed by the demands of an aging
relative, they may lash out physically or emotionally. Identifying these stressors early
allows for interventions such as respite care or support groups.
5. The nurse is caring for an older adult patient who is prescribed a new SSRI for depression.
Which side effect is of greatest concern in this population?
A. Increased appetite
B. Weight gain
C. Hyponatremia
D. Improved sleep patterns
Correct Answer: C
Expert Explanation: Older adults are at a higher risk for developing hyponatremia when
taking Selective Serotonin Reuptake Inhibitors (SSRIs). This condition occurs because
