A nurse is performing screening assessments for active older adult clients at a community clinic. Which of the following tests should the nurse include in the screening?
Geriatric Depression Scale
Pain Assessment in Advanced Dementia Scale
CAGE Questionnaire
Denver II Developmental Screening Test
The Correct Answer is A
Choice A reason:
The Geriatric Depression Scale (GDS) is a valuable tool for screening depression in older adults. Depression is common in this population and can significantly impact their quality of life. The GDS is specifically designed to identify symptoms of depression in the elderly, making it an essential part of the screening process for active older adults. The scale includes a series of questions that help determine the presence and severity of depressive symptoms. Early detection and treatment of depression can improve overall well-being and prevent further complications.
Choice B reason:
The Pain Assessment in Advanced Dementia (PAINAD) Scale is used to assess pain in individuals with advanced dementia who may not be able to communicate their pain verbally. While this tool is crucial for managing pain in dementia patients, it is not typically used for active older adults without dementia. The focus of the PAINAD Scale is on non-verbal cues and behaviors that indicate pain, which may not be relevant for the general active older adult population.
Choice C reason:
The CAGE Questionnaire is a screening tool for identifying potential alcohol abuse. It consists of four questions that help determine if an individual has issues with alcohol consumption. While alcohol abuse can be a concern in older adults, the CAGE Questionnaire is more specific to substance abuse rather than a general health screening for active older adults. It is important, but not as broadly applicable as the Geriatric Depression Scale for this context.
Choice D reason:
The Denver II Developmental Screening Test is designed to assess developmental progress in children from birth to six years old. It evaluates areas such as personal-social, fine motor-adaptive, language, and gross motor skills. This tool is not relevant for screening active older adults, as it is specifically tailored for identifying developmental delays in young children. Therefore, it would not be appropriate for use in a community clinic setting focused on older adults.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason:
Countertransference occurs when a healthcare provider projects their own personal feelings or experiences onto a client. In this case, the staff nurse is comparing the client to their brother, which indicates that the nurse's personal experiences are influencing their perception of the client. This can affect the nurse's objectivity and the quality of care provided. Recognizing and managing countertransference is crucial to maintaining professional boundaries and providing unbiased care.
Choice B Reason:
Stating that the client needs to accept responsibility for their substance use is a factual statement and does not indicate countertransference. It reflects an understanding of the importance of personal accountability in the recovery process. While the tone and approach of this statement should be empathetic and supportive, it does not suggest that the nurse's personal feelings are influencing their professional judgment.
Choice C Reason:
Noting that the client generally shares their feelings during group therapy sessions is an observational statement based on the client's behavior. It does not indicate countertransference, as it is a factual observation rather than a projection of the nurse's personal experiences or feelings. This type of statement is part of objective documentation and assessment in the therapeutic process.
Choice D Reason:
Refusing a client's inappropriate request, such as asking a nurse on a date, is a professional and appropriate response. It does not indicate countertransference but rather adherence to professional boundaries. The nurse's refusal is based on maintaining a therapeutic and professional relationship, which is essential in the care of clients with substance use disorders.
Correct Answer is A
Explanation
Choice A: Temperature
Reason: The client’s temperature is 39.4°C (103°F), which is significantly above the normal range of 36.5°C to 37.3°C (97.8°F to 99.1°F). This indicates a fever, which can be a sign of infection or other serious conditions that require immediate medical attention. In the context of a client taking antipsychotic medications like olanzapine, a high fever could also indicate neuroleptic malignant syndrome (NMS), a potentially life-threatening condition.
Choice B: Blood Pressure
Reason: The client’s blood pressure is 128/82 mmHg, which falls within the normal range of 90/60 mmHg to 120/80 mmHg. While slightly elevated, it is not critically high and does not require immediate reporting compared to the other findings.
Choice C: Weight Gain
Reason: The client reports a weight gain of 2.2 kg (4.9 lb) in the past week. While significant, weight gain is a common side effect of olanzapine. It is important to monitor, but it is not as urgent as the elevated temperature.
Choice D: Hallucinations
Reason: The client reports hearing voices, which is a symptom of schizophrenia. While this is important to manage, it is a known symptom of the client’s condition and is being treated with olanzapine. The immediate concern is the elevated temperature, which could indicate a more acute issue.
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