A 78-year-old nursing home resident with hypertension and cardiac disease is usually alert and oriented. This morning, however, the resident says, My family visited during the night. They stood by the bed and talked to me.
In reality, the patient's family lives 200 miles away. The nurse should first suspect that the resident:
a. may have a cognitive impairment associated with medication effects.
b. may be developing Alzheimers disease associated with advanced age.
c. had a transient ischemic attack and developed sensory perceptual alterations.
d. has a previously unidentified alcohol dependency and is beginning alcohol withdrawal delirium.
Question 2
A nurse asks the following questions while assessing an older adult. The nurse will add the Geriatric Depression Scale as part of the assessment if the patient answers yes to which question?
a. Would you say your mood is often low?
b. Are you having any trouble with your memory?
c. Have you noticed an increase in your alcohol use?
d. Do you often experience moderate-to-severe pain?
Physical assessment is one component of the nursing database
nursing team
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