Test Bank - Varcarolis\' Foundations of
Psychiatric Mental Health Nursing
(8th Edition) {Chapters 31-36}
C HAPTER 31: O LDER A DULTS
MULTIPLE CHOICE
1. In a sad voice, an elderl y patient tells the nurse of the recent deaths of a
spouse and close friend. The patient has no other famil y and onl y a few
acquaintances in the communit y. The nurses priorit y is to determine
whether which nursing diagnosis applies to this patient?
a. Risk for suicide related to recent deaths of significant others
b. Anxiet y related to sudden and abrupt lifestyle changes
c. Social isolation related to loss of existing famil y
d. Spiritual distress related to anger with God
ANS: A
The patient appears to be experiencing normal grief related to the loss
of her famil y, but because of age and social isolation, the risk for
suicide should be determined and has high priorit y. No defining
characteristics exist for the diagnoses of anxiet y or spiritual distress.
The patients social isolation is important, but the risk for suicide has
higher priorit y.
PTS: 1 DIF: Cognitive Level: Anal yze (Anal ysis) REF: 567
TOP: Nursing Process: Anal ysis/Diagnosis MSC: Client
Needs: Psychosocial Integrit y
2. When making a distinction as to whether an elderl y patient has confusion
related to delirium or another problem, what information would be of
particular value?
, a. Evidence of spasticity or flaccidit y
b. The patients level of motor activit y
c. Medications the patient has rece ntl y taken
d. Level of preoccupation with somatic sym ptoms
ANS: C
Delirium in the elderly produces symptoms of confusion. Medication
interactions or adverse reactions are often a cause. The distracters do
not give information important for delirium.
PTS: 1 DIF: Cognitive Level: Understand (Comprehension)
REF: 568 TOP: Nursing Process: Assessment MSC:
Client Needs: Physiological Integrit y
3. An 85-year-old has difficult y walking after a knee replacement. The
patient tells the nurse, Its awful to be o ld. Every day is a struggle. No one
cares about old people. Select the nurses best response.
a. Everyone here cares about old people. Thats why we work here.
b. It sounds like youre having a difficult time. Tell me about it.
c. Lets not focus on the negative. Tell me something good.
d. You are still able to get around, and your mind is alert.
ANS: B
The nurse uses empathetic understanding to permit the patient to
express frustration and clarify her struggle for the nurse. The
distracters block communication.
PTS: 1 DIF: Cognitive Level: Appl y (Application)
REF: 575 TOP: Nursing Process: Implementation
MSC: Client Needs: Psychosocial Integrity
4. A 76-year-old is regressed, indifferent, and responds to others onl y when
they initiate an interaction. What form of grou p therapy would be most
useful to promote resocialization?
a. Remotivation
, b. Activit y group
c. Psychotherapy
d. Reminiscence (life review)
ANS: A
Remotivation therapy helps to resocialize regressed and apathetic
patients by focusing on a single topic, creating a bridge to realit y as
group members talk about the world in which they live and work and
hobbies related to the topic. Group leaders give members acceptance
and appreciation. Group psychotherapy would not be effective for this
patient. An activit y group does not address the patients problem.
PTS: 1 DIF: Cognitive Level: Appl y (Application)
REF: 581 TOP: Nursing Process: Planning MSC:
Client Needs: Psychosocial Integrit y
5. A nurse assesses four patients between the ages of 70 and 80. Which
patient has the highest risk for alcohol abuse? The patient who:
a. consumes 1 glass of wine nightl y with dinner.
b. began drinking alcohol dail y after retirement and says, A few drinks
keep m y mind of f my arthritis.
c. drank sociall y throughout adult life and continues this pattern,
saying Ive earned the right to do as I please.
d. abused alcohol between the ages of 25 and 40 but now abstains and
occasionall y attends Alcoholics Anonymous (AA).
ANS: B
Alcohol abuse and dependence can develop at any age, and the geriatric
population is particularl y at risk. Losses, such as retirement,
widowhood, and loneliness, are often related. The distracters describe
patients with a lower risk for alcohol abuse.
PTS: 1 DIF: Cognitive Level: Anal yze (Anal ysis) REF: 568
TOP: Nursing Process: Assessment MSC: Client Needs:
Psychosocial Integrity
, 6. A nurse wants to assess for suicidal ideation in an elderl y patient. Select
the best question to begin this assessment.
a. Are there any things going on in your life that would cause you to
consider suicide?
b. What are your beliefs about a persons right to take his or her own
life?
c. Do you think you are vulnerable to developing a depressed mood?
d. If you felt suicidal, would you tell some one about your feelings?
ANS: B
This question is clear, direct, and respectful. It will produce
information relative to the acceptabilit y of suicide as an option to the
patient. If the patient deems suicide unacceptable, no further
assessment is necessary. If the patient deems suicide as acceptable, the
nurse can continue to assess intent, plan, means to carry out the plan,
lethalit y of the chosen method, and so forth. The other options are less
direct, may produce responses that may be unclear, o r are appropriate
for later in this discussion.
PTS: 1 DIF: Cognitive Level: Appl y (Application)
REF: 578 TOP: Nursing Process: Assessment MSC:
Client Needs: Psychosocial Integrit y
7. A communit y health nurse visits an elderly person whose spouse died 6
months ago. Two vodka bottles are in the trash. When the nurse asks about
alcohol use, this person says, I get lonel y and drink a little to help me
forget. Select the nurses most therapeutic intervention.
a. Assess whether this patient is drinking and drivin g.
b. Advise the person not to drink alone because the risks for injury
increase.
c. Teach the person about risks for alcoholism and suggest other
coping strategies.
d. Arrange for the person to attend an Alcoholics Anonymous meeting
for older adults.
ANS: D
Psychiatric Mental Health Nursing
(8th Edition) {Chapters 31-36}
C HAPTER 31: O LDER A DULTS
MULTIPLE CHOICE
1. In a sad voice, an elderl y patient tells the nurse of the recent deaths of a
spouse and close friend. The patient has no other famil y and onl y a few
acquaintances in the communit y. The nurses priorit y is to determine
whether which nursing diagnosis applies to this patient?
a. Risk for suicide related to recent deaths of significant others
b. Anxiet y related to sudden and abrupt lifestyle changes
c. Social isolation related to loss of existing famil y
d. Spiritual distress related to anger with God
ANS: A
The patient appears to be experiencing normal grief related to the loss
of her famil y, but because of age and social isolation, the risk for
suicide should be determined and has high priorit y. No defining
characteristics exist for the diagnoses of anxiet y or spiritual distress.
The patients social isolation is important, but the risk for suicide has
higher priorit y.
PTS: 1 DIF: Cognitive Level: Anal yze (Anal ysis) REF: 567
TOP: Nursing Process: Anal ysis/Diagnosis MSC: Client
Needs: Psychosocial Integrit y
2. When making a distinction as to whether an elderl y patient has confusion
related to delirium or another problem, what information would be of
particular value?
, a. Evidence of spasticity or flaccidit y
b. The patients level of motor activit y
c. Medications the patient has rece ntl y taken
d. Level of preoccupation with somatic sym ptoms
ANS: C
Delirium in the elderly produces symptoms of confusion. Medication
interactions or adverse reactions are often a cause. The distracters do
not give information important for delirium.
PTS: 1 DIF: Cognitive Level: Understand (Comprehension)
REF: 568 TOP: Nursing Process: Assessment MSC:
Client Needs: Physiological Integrit y
3. An 85-year-old has difficult y walking after a knee replacement. The
patient tells the nurse, Its awful to be o ld. Every day is a struggle. No one
cares about old people. Select the nurses best response.
a. Everyone here cares about old people. Thats why we work here.
b. It sounds like youre having a difficult time. Tell me about it.
c. Lets not focus on the negative. Tell me something good.
d. You are still able to get around, and your mind is alert.
ANS: B
The nurse uses empathetic understanding to permit the patient to
express frustration and clarify her struggle for the nurse. The
distracters block communication.
PTS: 1 DIF: Cognitive Level: Appl y (Application)
REF: 575 TOP: Nursing Process: Implementation
MSC: Client Needs: Psychosocial Integrity
4. A 76-year-old is regressed, indifferent, and responds to others onl y when
they initiate an interaction. What form of grou p therapy would be most
useful to promote resocialization?
a. Remotivation
, b. Activit y group
c. Psychotherapy
d. Reminiscence (life review)
ANS: A
Remotivation therapy helps to resocialize regressed and apathetic
patients by focusing on a single topic, creating a bridge to realit y as
group members talk about the world in which they live and work and
hobbies related to the topic. Group leaders give members acceptance
and appreciation. Group psychotherapy would not be effective for this
patient. An activit y group does not address the patients problem.
PTS: 1 DIF: Cognitive Level: Appl y (Application)
REF: 581 TOP: Nursing Process: Planning MSC:
Client Needs: Psychosocial Integrit y
5. A nurse assesses four patients between the ages of 70 and 80. Which
patient has the highest risk for alcohol abuse? The patient who:
a. consumes 1 glass of wine nightl y with dinner.
b. began drinking alcohol dail y after retirement and says, A few drinks
keep m y mind of f my arthritis.
c. drank sociall y throughout adult life and continues this pattern,
saying Ive earned the right to do as I please.
d. abused alcohol between the ages of 25 and 40 but now abstains and
occasionall y attends Alcoholics Anonymous (AA).
ANS: B
Alcohol abuse and dependence can develop at any age, and the geriatric
population is particularl y at risk. Losses, such as retirement,
widowhood, and loneliness, are often related. The distracters describe
patients with a lower risk for alcohol abuse.
PTS: 1 DIF: Cognitive Level: Anal yze (Anal ysis) REF: 568
TOP: Nursing Process: Assessment MSC: Client Needs:
Psychosocial Integrity
, 6. A nurse wants to assess for suicidal ideation in an elderl y patient. Select
the best question to begin this assessment.
a. Are there any things going on in your life that would cause you to
consider suicide?
b. What are your beliefs about a persons right to take his or her own
life?
c. Do you think you are vulnerable to developing a depressed mood?
d. If you felt suicidal, would you tell some one about your feelings?
ANS: B
This question is clear, direct, and respectful. It will produce
information relative to the acceptabilit y of suicide as an option to the
patient. If the patient deems suicide unacceptable, no further
assessment is necessary. If the patient deems suicide as acceptable, the
nurse can continue to assess intent, plan, means to carry out the plan,
lethalit y of the chosen method, and so forth. The other options are less
direct, may produce responses that may be unclear, o r are appropriate
for later in this discussion.
PTS: 1 DIF: Cognitive Level: Appl y (Application)
REF: 578 TOP: Nursing Process: Assessment MSC:
Client Needs: Psychosocial Integrit y
7. A communit y health nurse visits an elderly person whose spouse died 6
months ago. Two vodka bottles are in the trash. When the nurse asks about
alcohol use, this person says, I get lonel y and drink a little to help me
forget. Select the nurses most therapeutic intervention.
a. Assess whether this patient is drinking and drivin g.
b. Advise the person not to drink alone because the risks for injury
increase.
c. Teach the person about risks for alcoholism and suggest other
coping strategies.
d. Arrange for the person to attend an Alcoholics Anonymous meeting
for older adults.
ANS: D
