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,

Question

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

Answer 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.