Which statement made by a patient during an initial assessment ...

[crazycityslicker]

Which statement made by a patient during an initial assessment interview should serve as the priority focus for the plan of care?
 
  a. I can always trust my family.
  b. It seems like I always have bad luck.
  c. You never know who will turn against you.
  d. I hear evil voices that tell me to do bad things.

Question 2

A nurse assesses an older adult patient brought to the emergency department by a family member. The patient was wandering outside, saying, I can't find my way home. The patient is confused and unable to answer questions. Select the nurse's best action.
 
  a. Document the patient's mental status. Obtain other assessment data from the family member.
  b. Record the patient's answers to questions on the nursing assessment form.
  c. Ask an advanced practice nurse to perform the assessment interview.
  d. Call for a mental health advocate to maintain the patient's rights.

[maya.nigrin17@yahoo.com]

Answer to Question 1

ANS: D
The statement regarding evil voices tells the nurse that the patient is experiencing auditory hallucinations. The other statements are vague and do not clearly identify the patient's chief symptom.

Answer to Question 2

ANS: A
When the patient (primary source) is unable to provide information, secondary sources should be used, in this case the family member. Later, more data may be obtained from other relatives or neighbors who are familiar with the patient. An advanced practice nurse is not needed for this assessment; it is within the scope of practice of the staff nurse. Calling a mental health advocate is unnecessary.