The nurse is performing a focused interview with an older adult ...

[genevieve1028]

The nurse is performing a focused interview with an older adult client. Which statements indicate the client has an increased risk of developing depression? Select all that apply.
 
  1. I've been so lonely since my wife, Maggie, passed away 2 months ago.
  2. My mother had a history of depression.
  3. I was diagnosed with chronic bronchitis 4 years ago.
  4. My son visits at least once a week and takes care of my financial stuff.
  5. I visit my sister every Monday and she makes me dinner.

Question 2

The nurse is preparing to interview the older adult client and perform a head-to-toe assessment. Which actions by the nurse are appropriate? Select all that apply.
 
  1. The nurse has requested that the client put on a cotton gown prior to the interview.
  2. The nurse seats the client so that the light from the window faces the client with the nurse's back to the window.
  3. The nurse addresses the client by her first name.
  4. The nurse maintains eye contact; both nurse and client are seated.
  5. During the interview, the nurse asks if the client is currently experiencing any pain or anxiety before proceeding further.

[beccamahon]

Answer to Question 1

Correct Answer: 1, 2, 3
Loneliness is a risk factor for the development of depression. A family history of depression increases the client's risk. Chronic illnesses such as chronic bronchitis increase the client's risk for becoming depressed. This client's son visits. The client has evidence of a social support system. The client visits a sibling each week. This is more evidence of the presence of a social support system.

Answer to Question 2

Correct Answer: 4, 5
The nurse should maintain good eye contact during the interview and assessment. The nurse and client should be able to communicate at eye level. The nurse should assess the client's level of pain and anxiety to ensure that the client does not require pain medication or an intervention prior to continuing with the interview and assessment. Thin cotton examining gowns often make the older client feel uncomfortably chilly and less able to attend to the health history questions. The nurse could provide the client with a robe or wait to request that the client put on a gown until following the interview. The client should have her back to the window or strong light source. Thus glare is reduced, and the light falls upon the face of the examiner. The nurse should address the client using her last name until the client states that it is appropriate to be more informal.