A nurse is observed conducting an assessment interview for a ...

[james0929]

A nurse is observed conducting an assessment interview for a newly admitted client. Which of the following would require immediate follow-up by the nurse's mentor?
 
  1. Conducting the interview with the client's boyfriend present
  2. Stopping the interview to answer a page from the nursing station
  3. Frequently checking the time while waiting for the client to answer
  4. Heard asking the client, Am I correct; you've rated your pain a 9 out of 10?

Question 2

When following up on a client's report of hip pain during an admission assessment, the most nursing conclusive observation would be:
 
  1. The client tearing when being ambulated to the chair
  2. A report from the ancillary staff that the client is reporting pain
  3. The client observed grimacing when positioning self in the bed
  4. Overhearing the client discuss hip pain with family on the phone

[johnharpe]

Answer to Question 1

ANS: 3
Clients are less likely to fully reveal the nature of their health care problems when nurses show little interest, appear rushed, or are easily distracted by activities around them. As long as the nurse had the client's permission, this would not require follow-up. While interrupting an assess-ment is not recommended, a page is an example of an acceptable exception and so this would not require follow-up. If the nurse were confirming the information, it would not require follow-up. If the mentor felt the nurse was questioning the validity of client's pain rating, a follow-up would be appropriate because a client's pain rating should not be questioned.

Answer to Question 2

ANS: 3
This option where the client was observed grimacing describes nonverbal actions that are associ-ated with pain when the client is unaware of being observed and so represents the most conclu-sive follow-up evidence of pain. The options where the client is tearing when ambulated to the chair, the ancillary staff's report of the client's pain as well as overhearing the client discuss hip pain may well be an observation of pain, but they are not the most conclusive of the options be-cause the client is aware of being observed.