C HAPTER 31: O LDER A DULTS
Halter: Varcarolis’ Foundations of Psychiatric -Mental Health Nursing: A
Clinical Approach, 9th Edition
MULTIPLE CHOICE
1. A 79-year-old adult tells a nurse, “I have felt very sad latel y. I do not
have much to live for. My famil y and friends are all dead , and m y own
health is failing.” The nurse should anal yze this comment as suggestive of
what?
a. normal pessimism of the elderl y.
b. evidence of risks for suicide.
c. a call for sympathy.
d. normal grieving.
ANS: B
The client describes loss of significant others, ec onomic securit y, and
health. He describes mood alteration and voices the thought that he has
little to live for. Combined with his age, sex, and single status, each is
a risk factor for suicide. Elderl y white males have the highest risk for
completed suici de.
PTS: 1 DIF: Cognitive Level: Understand (Comprehension)
TOP: Nursing Process: Anal ysis | Nursing Process:
Diagnosis MSC: Client Needs: Psychosocial Integrity
,2. In a sad voice, an elderl y client tells the nurse of the recent deaths of a
spouse and close friend. The client has no other famil y and only a few
acquaintances in the communit y. The nurse’s priorit y is to determine
whether which nursing diagnosis applies to this client?
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 client appears to be experiencing normal grief related to the loss
of her famil y, but because of a ge 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 client’s social isolation is important, but the risk for suicide has
higher priorit y.
PTS: 1 DIF: Cognitive Level: Anal yze (Anal ysis) TOP:
Nursing Process: Anal ysis | Nursing Process: Diagnosis
MSC: Client Needs: Psychosocial Integrity
3. When making a distinction as to whether an elderl y client is experiencing
confusion relat ed to delirium or another problem, what information would
be of particular value?
a. Evidence of spasticity or flaccidit y
b. The client’s level of motor activit y
c. Medications the client has recentl 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)
TOP: Nursing Process: Assessment MSC: Client Needs:
Physiological Integrity
4. An 85-year-old has difficult y walking after a knee replacement. The client
tells the nurse, “It’s awful to be old. Every day is a struggle. No one cares
about old people.” What is the nurse’s b est response?
a. “Everyone here cares about old people. That’s why we work here.”
b. “It sounds like you’re having a difficult time. Tell me about it.”
c. “Let’s 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 client to express
frustration and clarify her “struggle” for the nurse. The distracters
block communication.
PTS: 1 DIF: Cognitive Level: Appl y (Application)
TOP: Nursing Process: Implementation MSC: Client
Needs: Psychosocial Integrit y
Halter: Varcarolis’ Foundations of Psychiatric -Mental Health Nursing: A
Clinical Approach, 9th Edition
MULTIPLE CHOICE
1. A 79-year-old adult tells a nurse, “I have felt very sad latel y. I do not
have much to live for. My famil y and friends are all dead , and m y own
health is failing.” The nurse should anal yze this comment as suggestive of
what?
a. normal pessimism of the elderl y.
b. evidence of risks for suicide.
c. a call for sympathy.
d. normal grieving.
ANS: B
The client describes loss of significant others, ec onomic securit y, and
health. He describes mood alteration and voices the thought that he has
little to live for. Combined with his age, sex, and single status, each is
a risk factor for suicide. Elderl y white males have the highest risk for
completed suici de.
PTS: 1 DIF: Cognitive Level: Understand (Comprehension)
TOP: Nursing Process: Anal ysis | Nursing Process:
Diagnosis MSC: Client Needs: Psychosocial Integrity
,2. In a sad voice, an elderl y client tells the nurse of the recent deaths of a
spouse and close friend. The client has no other famil y and only a few
acquaintances in the communit y. The nurse’s priorit y is to determine
whether which nursing diagnosis applies to this client?
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 client appears to be experiencing normal grief related to the loss
of her famil y, but because of a ge 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 client’s social isolation is important, but the risk for suicide has
higher priorit y.
PTS: 1 DIF: Cognitive Level: Anal yze (Anal ysis) TOP:
Nursing Process: Anal ysis | Nursing Process: Diagnosis
MSC: Client Needs: Psychosocial Integrity
3. When making a distinction as to whether an elderl y client is experiencing
confusion relat ed to delirium or another problem, what information would
be of particular value?
a. Evidence of spasticity or flaccidit y
b. The client’s level of motor activit y
c. Medications the client has recentl 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)
TOP: Nursing Process: Assessment MSC: Client Needs:
Physiological Integrity
4. An 85-year-old has difficult y walking after a knee replacement. The client
tells the nurse, “It’s awful to be old. Every day is a struggle. No one cares
about old people.” What is the nurse’s b est response?
a. “Everyone here cares about old people. That’s why we work here.”
b. “It sounds like you’re having a difficult time. Tell me about it.”
c. “Let’s 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 client to express
frustration and clarify her “struggle” for the nurse. The distracters
block communication.
PTS: 1 DIF: Cognitive Level: Appl y (Application)
TOP: Nursing Process: Implementation MSC: Client
Needs: Psychosocial Integrit y
