A nurse in a long-term care facility is assessing an older adult client for depression. Which of the following findings should the nurse expect?
Rambling speech
Insomnia
Rapid mood swings
Sundowning
The Correct Answer is B
A. Rambling speech
Rambling speech is not a typical finding associated with depression. It may indicate other conditions or issues.
B. Insomnia
Insomnia, or difficulty sleeping, is a common symptom of depression. Many individuals with depression experience trouble falling asleep, staying asleep, or both.
C. Rapid mood swings
Rapid mood swings are not typically associated with depression. Depression often involves persistent low mood rather than rapid fluctuations.
D. Sundowning
Sundowning refers to a state of confusion and restlessness that occurs in the late afternoon and evening, often seen in individuals with dementia. While it can be related to mood disturbances, it's not specific to depression.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Determine the client's degree of physical dependence:
This action is important but usually comes after the initial assessment and documentation. Assessing the degree of physical dependence involves evaluating the client's withdrawal symptoms, tolerance, and other physical health parameters. It helps in planning the appropriate level of care, such as detoxification if needed.
B. Discuss the treatment plan with the client:
While discussing the treatment plan is crucial, it's typically done after gathering essential information about the client's alcohol use, medical history, and current condition. The treatment plan is tailored based on the gathered data, which includes documenting the client's alcohol use.
C. Document the client's alcohol use in the medical record:
This is the first step because it provides a formal record of the client's alcohol use history, including patterns and any associated complications. Documenting this information helps in comprehensive care planning and ensures that all healthcare providers involved in the client's treatment have accurate and up-to-date information.
D. Initiate a referral for treatment for alcohol use disorder:
Referrals are essential, but they usually follow the initial assessment and documentation. The referral process involves connecting the client with appropriate resources, such as addiction specialists, counselors, or support groups, based on the documented information and the client's needs.
Correct Answer is C
Explanation
A. Request a prescription for varenicline from the client's provider.
Varenicline is used to help people quit smoking and is not indicated for the treatment of opioid use disorder.
B. Initiate facility procedures for emergency commitment.
Emergency commitment typically involves legal procedures and should only be pursued if the client poses an immediate danger to themselves or others. It is not the appropriate action in this scenario without further information indicating such a need.
C. Inform the client about policies for dispensing methadone.
Methadone is a medication used to help people reduce or quit their use of heroin or other opiates. Methadone is dispensed under strict regulations and guidelines due to its potential for misuse. The nurse should inform the client about the policies and procedures related to the dispensing of methadone, ensuring the client understands the rules and requirements associated with its use.
D. Assess the client using the CAGE questionnaire.
The CAGE questionnaire is a tool used to screen for alcohol use disorder, not opioid use disorder. While it's essential to assess the client comprehensively, using appropriate tools, in this case, informing the client about methadone dispensing policies is the most relevant action.
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