When assessing older adults, the nurse knows that one of the first things that should be assessed before drawing conclusions about their mental health is:

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Question 1 of 5

When assessing older adults, the nurse knows that one of the first things that should be assessed before drawing conclusions about their mental health is:

Correct Answer: D

Rationale: The correct answer is D: Their sensory-perceptive abilities. Assessing sensory-perceptive abilities is crucial in older adults as sensory impairments can mimic signs of mental health issues. By assessing sensory functions first, the nurse can rule out any physical factors influencing the assessment. Phobias (A) and irrational thinking patterns (C) are psychological aspects that come after ruling out sensory issues. General intelligence (B) may not be the priority as cognitive decline can be affected by sensory impairments.

Question 2 of 5

Which of the following would illustrate an auditory hallucination?

Correct Answer: A

Rationale: The correct answer is A because an auditory hallucination involves hearing something that is not actually present. In this scenario, the man is hearing his dead wife talking to him, which is a perception without an external auditory stimulus. This illustrates an auditory hallucination. Choice B is incorrect as it describes a visual hallucination, seeing the doorbell indicator light up and hearing the bell ring. Choice C is also incorrect as it describes a visual misperception, seeing a man in the closet that turns out to be a dry cleaning bag. Choice D is incorrect as it describes a misinterpretation of a visual stimulus, mistaking a blanket for a dog.

Question 3 of 5

A score of 6 on the MoCA tool indicates:

Correct Answer: D

Rationale: A score of 6 on the MoCA tool indicates severe cognitive impairment because the MoCA is scored out of 30, with a lower score indicating more severe impairment. A score of 6 is significantly below the normal range, indicating severe cognitive deficits affecting various cognitive domains. This score would suggest significant impairment in memory, attention, language, visuospatial abilities, and executive functions. Therefore, Option D is correct. Options A, B, and C are incorrect as they suggest no, mild, or moderate impairment, which would not align with a score as low as 6 on the MoCA tool.

Question 4 of 5

A patient is found to have an irregular, jagged scar that is raised and red. The nurse would classify this as:

Correct Answer: B

Rationale: The correct answer is B: Hypertrophic scar. This type of scar is raised, red, and irregular, but it does not extend beyond the boundaries of the original wound like a keloid. A keloid is characterized by excessive scar tissue that grows beyond the wound site. Contracture is a scar that causes tightening of the skin and may restrict movement. Stretch marks, on the other hand, are not raised or irregular like the described scar.

Question 5 of 5

A 50-year-old male patient with chronic back pain is prescribed a medication for pain management. Which of the following would be the nurse's priority assessment after administering the medication?

Correct Answer: C

Rationale: The correct answer is C: Assessing the patient's respiratory status. After administering pain medication, especially opioids, it is crucial to monitor the patient's respiratory status due to the risk of respiratory depression. This assessment is a priority because respiratory depression can be life-threatening. Other choices are not as immediate: A, assessing for addiction, can be done but is not as critical at this moment; B, assessing pain level, is important but comes after ensuring the patient's safety; D, assessing for infection, is not directly related to the immediate effects of pain medication.

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