A nurse on an acute care for elders (ACE) unit monitors clients for functional consequences of depression. Which of the following statements by a client is of highest priority for follow-up?
A) I can't shake this feeling that I've got a cloud hanging over me these days.
B) I feel like I've got no appetite these days and it takes everything in me just to eat a little meal.
C) I used to be a powerhouse of energy when I was younger, and now all I can do is sit in a chair.
D) I think it would be better for everyone if I wasn't here anymore.
Question 2An older adult is admitted to the hospital with weight loss and cognitive impairment. To assist in the diagnosis of major depressive disorder, for which of the following should the nurse assess? (Select all that apply.)
A) Decreased deep tendon reflexes
B) Loss of interest or pleasure
C) Psychomotor agitation
D) Respiratory difficulty
E) Sleep disturbances
Question 3Which of the following statements by residents of a nursing home should prompt a nurse to assess for depression?
A) Lately I wake up for the day at 4:00 or 5:00 in the morning and can't fall asleep again.
B) I've got these cravings for sugary and salty snacks more than I used to.
C) I've never been too prone to headaches, but these days I always seem to have one.
D) I don't know why this sore on my ankle just won't heal this time.
Question 4An older adult has been accompanied by an adult child to visit a primary care provider. The child has expressed concern about the client's increasing apathy, isolation, and apparent sadness over the past several months;
and the client acknowledges many of the symptoms of depression. Which of the following assessments should the nurse prioritize?
A) Functional assessment
B) Medication assessment
C) Musculoskeletal assessment
D) Cardiovascular assessment
Question 5A gerontological nurse conducts an assessment of an older adult who has a history of depression. Assessment reveals that the client has been drinking up to two bottles of wine each day for the last several months.
What should the nurse teach the client about alcohol use and depression?
A) If you choose to use alcohol to address your depression, it's best to limit it to four to five drinks each day.
B) We recommend that everyone over the age of 70 abstain from drinking alcohol.
C) Alcohol has been shown to contribute to depression and vice versa.
D) If you quit drinking, your depression will likely improve.
Question 6A nurse educator teaches about theories of late-life depression. Which of the following statements by a student shows that the material is understood?
A) Adverse events impair your ability to evaluate yourself.
B) Depression is caused by decreased activity in the hypothalamicpituitaryadrenal axis.
C) Older adults with depression and chronic illness have more serious negative functional consequences.
D) Researchers have identified a cause-and-effect relationship between depression and dementia.
Question 7When risk factors to potential suicide have been identified, a nurse must further assess the actual risk for a suicide attempt.
Which of the following questions would be appropriate for initial assessment to determine the presence or absence of suicidal thoughts in an older adult with risk factors?
A) Under what circumstances would you take your life? Have you ever started to act on a plan to harm yourself?
B) Do you have a plan for taking your life? What action would you take if you were to harm yourself?
C) Does your life feel worthless? Do you ever think about escaping from your problems?
D) Do you think about harming yourself? Do you ever think about committing suicide?
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