ATI LPN
Test Bank for Psychiatric Nursing: Contemporary Practice
Chapter 37 : Mental Health Assessment of Older Adults Questions
Question 1 of 5
The nurse is assessing a client who has a history of heavy drinking and who lost his wife to cancer during the previous year. He reports that he isn?t getting as much sleep as he used to when he was younger. Which question would be most appropriate to ask the client to determine if the change in his sleep pattern is related to normal aging or depression?
Correct Answer: B
Rationale: Difficulty falling or staying asleep (option
B) is a key symptom of depression, especially in the context of recent loss and heavy drinking, which can exacerbate depressive symptoms. Normal aging may reduce sleep duration slightly, but insomnia is more indicative of depression. Options A, C, and D provide background but do not directly differentiate between aging and depression.
Question 2 of 5
A couple is concerned that the husband?s father may be developing depression. In questioning the couple, which of the following statements would support their concern?
Correct Answer: C
Rationale: Persistent crying, inability to eat, and sleep difficulties for over 2 months (option
C) strongly suggest depression, as these symptoms exceed normal grief duration (typically lessening within 2 months). Option A (2 weeks) and option D (1 week) reflect acute grief, which is more expected. Option B (agitation and anxiety) is less specific to depression and could indicate other conditions.
Question 3 of 5
A nurse is providing an in-service educational program for beginning nurses regarding mental health assessment needs of the older adult. One of the topics addressed is the importance of interviewing family members in addition to the older adult client. The nurse tells the audience that family members are sometimes able to give a more accurate history if the client has memory impairment. The nurse also emphasizes that interviewing family members provides which of the following?
Correct Answer: A
Rationale: Interviewing family members provides a clearer picture of the client?s social support resources (option
A), which is critical for assessing the older adult?s ability to manage mental health challenges. Option B focuses on caregiver ability, which is secondary. Option C is partially correct but less comprehensive, as memory impairment is only one aspect. Option D is incorrect, as interviews are not primarily for family respite.
Question 4 of 5
Assessment of an older adult client reveals that the client is receiving psychiatric medications. The client states, 'I get dizzy periodically and have trouble walking.' Which of the following should the nurse do first?
Correct Answer: A
Rationale: Dizziness and walking difficulties in an older adult on psychiatric medications may indicate orthostatic hypotension, a common side effect. Comparing baseline and current blood pressure (option
A) is the first step to assess this. Stopping medications (option
B) is premature without evidence. Interviewing family (option
C) is secondary to physical assessment. Mouthwash (option
D) is irrelevant to the symptoms.
Question 5 of 5
The nurse is planning to assess a client?s anxiety level using the Rating Anxiety in Dementia Scale because the client also has dementia. When using this scale which of the following areas would the nurse assess? Select all that apply.
Correct Answer: A,B,E,F
Rationale: The Rating Anxiety in Dementia Scale assesses anxiety symptoms in dementia patients, including apprehension (
A), motor tension (
B), autonomic hyperactivity (E), and worry (F). Life satisfaction (
C) and boredom (
D) are not specific components of this scale, which focuses on anxiety-related behaviors and physiological signs.