The nurse is caring for an older adult patient who has no history of violence but is agitated and appears ready to strike out at a staff member. The nurse would assess the patient for which of the following?

Correct Answer: D

Rationale: The correct answer is D: Sensory losses. In this scenario, the older adult patient's agitation and readiness to strike out may be due to sensory losses such as hearing or vision impairment, leading to frustration and miscommunication. Assessing for sensory losses is crucial to understand the root cause of the patient's behavior and provide appropriate interventions. A: Panic disorder - This choice is incorrect as panic disorder typically presents with sudden and intense episodes of fear or anxiety, not necessarily leading to physical aggression. B: Epilepsy - This choice is incorrect as epilepsy is a neurological disorder characterized by seizures, not typically associated with sudden aggression. C: Bipolar disorder - This choice is incorrect as bipolar disorder involves distinct episodes of mania and depression, which may not directly cause the patient's behavior in this situation.

Correct Answer: C

Rationale: The correct answer is C because family members are often the primary support system for individuals with serious mental illness. In treatment planning, involving the family can provide crucial insights into the patient's social and emotional needs, enhance communication between the patient and healthcare providers, and increase the likelihood of treatment adherence. Family support can also help in crisis situations and promote better outcomes for the patient. Choice A is incorrect because while family members may have valuable insights, they may not always know the patient's struggles comprehensively. Choice B is incorrect as willingness to listen is not a guarantee, especially in cases where mental illness may affect the patient's judgment. Choice D is incorrect as the patient may not always turn to family first, especially if the relationship is strained or if the family is not supportive.

Correct Answer: A

Rationale: The correct answer is A because the sudden onset of confusion is a key characteristic of delirium, whereas dementia typically has a gradual progression. Choice B suggests a symptom of dementia - progressive memory loss. Choice C indicates a hallucination, which can occur in both delirium and dementia. Choice D describes memory and cognitive impairment, which can be seen in both conditions but is more indicative of dementia due to the chronic nature of forgetfulness.

Correct Answer: C

Rationale: The correct answer is C because short, time-limited interactions are best for clients experiencing psychosis due to their limited attention span and potential for increased anxiety. Lengthy interactions may overwhelm the client and hinder the development of trust and rapport. A: The relationship typically develops over a short period of time - Incorrect. Building a therapeutic relationship with a client with schizophrenia takes time due to trust issues and symptom severity. B: Decisions about care are the responsibility of interdisciplinary team - Incorrect. While involving the interdisciplinary team is important, the nurse-patient relationship is crucial in promoting recovery. D: Typically, clients with schizophrenia readily engage in a therapeutic relationship - Incorrect. Clients with schizophrenia may have difficulties in engaging due to symptoms such as paranoia and disorganized thinking.

Correct Answer: C

Rationale: The correct answer is C: functional abilities. A comprehensive geriatric assessment should focus on assessing the older adult's functional abilities to determine their ability to carry out activities of daily living independently. This is crucial in evaluating their overall health and quality of life. By assessing functional abilities, nurses can identify areas of impairment and develop appropriate interventions to maintain or improve the client's independence. Physical signs of aging (Choice A) may provide some information about the client's health status, but focusing solely on this aspect may overlook important functional deficits. Immunological function (Choice B) is important but may not be the primary focus of a geriatric assessment unless specific health concerns are present. Chronic illness (Choice D) is also important to consider but does not encompass the holistic assessment of functional abilities needed in geriatric care.