An 88-year-old, being admitted to rule out lung cancer, is assessed using the short form of the Geriatric Depression Scale tool. When it is determines that the earned score is 9, the nurse initially:
a. asks if they have any thoughts of committing suicide
b. recognizes that this score is not indicative of depression
c. knows it is not unusual for clients this age to earn such a score
d. notifies the client's healthcare provider immediately
ANS: A
The shortened version of this assessment tool does not specifically address the presence of suicidal ideations. With a score of 9, which generally indicates depression, this limitation of the tool must be addressed with a specific question. It is not to be considered usual for an older to score such a high score. The heath care provider needs to be made aware of the re-sults of the assessment but the focused question regarding suicide should be asked first.
You might also like to view...
The nurse is assessing a terminally ill patient for clinical signs of impending death. When assessing the patient's respirations, the nurse would expect:
1. deep, clear breath sounds. 2. noisy, wet-sounding respirations. 3. even, unlabored respirations. 4. shallow, clear breath sounds.
Infants less than one year old should not be fed
a. crackers. b. egg yolk. c. cow's milk. d. fruit juice.
A mother who is bottlefeeding her newborn is discharged 48 hours postdelivery. When should the nurse schedule the first office visit for the newborn with the pediatrician?
1. Within 5 days of discharge 2. Within 7 days of discharge 3. Within 2 weeks of discharge 4. Within 3 weeks of discharge
When taking postoperative vital signs, you should
A. monitor the temperature every 15 minutes. B. count the pulse and respiration for one full minute. C. discontinue monitoring one hour after the patient returns. D. discontinue monitoring when you think the patient is stable.