A nurse is assigned to perform the assessment interview for a ...

[tfester]

A nurse is assigned to perform the assessment interview for a 65-year-old woman brought to the
  hospital emergency department by her 16-year-old granddaughter,
 
  who found her wandering around
  the yard of her suburban home, saying I can't find my way home.. The nurse finds the client to be
  so profoundly confused that she is unable to respond to or answer any questions posed. In this case
  the nurse should
  a. persevere and record the client's answers to questions on the agency assessment
  form.
  b. document the client's confusion and obtain as much data as possible from the
  granddaughter.
  c. ask a more experienced nurse to perform the interview.
  d. call for a mental health advocate to support the client's rights.

Question 2

Approximately 45 minutes ago, the nurse administered a prn anxiolytic to a client who was feeling
  acutely anxious.
 
  The nurse, who has been sitting with the client, asks On a scale of 1 to 10, how
  would you rate your anxiety at the moment? Which basic nursing intervention does this interaction
  characterize?
  a. Counseling
  b. Milieu management
  c. Culturally relevant health promotion
  d. Administering and monitoring psychobiological interventions

[carojassy25]

Answer to Question 1

ANS: B
When the client (primary source) is unable to provide information, secondary sources should be
used, in this case the granddaughter. Later, more data may be obtained from other relatives or
neighbors who are familiar with the client. Option C: An experienced nurse would probably do no
better. Option D is unnecessary.

Answer to Question 2

ANS: D
Administering psychopharmacologic al drugs and monitoring the client's response to them is the
basic level intervention described. Option A: Counseling would involve activities such as
interviewing, problem solving, and conflict resolution. Option B: Milieu management would involve
use of the environment to influence behavior. Option C: Health promotion would involve activities
to enhance mental health.