The nurse at a local health clinic is assessing an older adult ...

[Shelles]

The nurse at a local health clinic is assessing an older adult male who may have broken his leg. The patient's vital signs are within normal limits. The patient is alert and oriented to time, person, and place,
 
  but reports falling off the ladder while trying to change a light bulb. The patient states, I'm just a mess. I'm no good at anything anymore. Which is the nurse likely to include as part of the assessment? Select all that apply.
  1. A sleep assessment
  2. A nutrition evaluation
  3. A depression inventory
  4. A substance abuse assessment
  5. A pulmonary assessment

Question 2

The nurse at a mental health clinic is conducting an initial assessment on a patient who has been referred by the student health center at the university the patient attends. The patient had been brought to the health center by a member of the faculty
 
  when the patient began hallucinating during class. Which factor revealed during the assessment will the nurse consider a priority for care?
  1. The patient has poor hygiene.
  2. The patient is 20 years old.
  3. The patient is single and lives off campus with a roommate who is never around.
  4. The patient's grades have plummeted this semester.

[SeanoH09]

Answer to Question 1

Answer: 2, 3, 4
Explanation: Older adult males are one of the populations at increased risk for suicide. As an older adult male who has expressed feelings of worthlessness, this patient requires screening for depression. Older adults are at risk for poor nutrition and fluid and electrolyte imbalance, and any of these may affect mobility, so a nutrition screening and assessment of fluid and electrolyte balance would be appropriate. Substance abuse among older adults is on the rise, so a screening for substance abuse would be appropriate as substance abuse could increase the patient's risk for injury. The patient is alert and oriented, so there is no indication a mental status examination is necessary. There is no indication at this time that the patient is having trouble sleeping or that a sleep assessment is necessary.

Answer to Question 2

Answer: 3
Explanation: The single adult patient with initial onset schizophrenia with active hallucinations and/or delusions is at risk for injury due to the active state of illness and the patient's lack of knowledge about the illness. The fact that the patient lives essentially alone in an off campus apartment suggests he may have little in the way of support or observation. The patient's age, poor hygiene, and plummeting grades support the diagnosis of mental illness but are not the priority consideration in planning care.