During the initial interview of a patient, the nurse should: (Select all that apply.)
assess the language capabilities of the patient.
limit the interview to approximately 30 minutes.
assess comprehension abilities of the patient.
make the patient as comfortable as possible.
use open-ended questions.
obtain the patient's medical history from the primary care provider.
Correct Answer : A,C,D,E
A. Assess the language capabilities of the patient. Understanding the patient’s language capabilities is essential for effective communication and ensuring that the patient can understand the questions being asked.
B. Limit the interview to approximately 30 minutes. While it’s important to manage time, the interview should be flexible based on the patient’s needs and the complexity of the issues being discussed. Rigidly limiting the time could hinder the quality of the assessment.
C. Assess comprehension abilities of the patient. Assessing comprehension helps the nurse determine whether the patient understands the information being provided and can respond appropriately during the interview.
D. Make the patient as comfortable as possible. Creating a comfortable environment is crucial in fostering open communication and trust, which can lead to a more effective interview process.
E. Use open-ended questions. Open-ended questions encourage the patient to provide more detailed responses and express their feelings or concerns, facilitating a better understanding of their situation.
F. Obtain the patient's medical history from the primary care provider. Although obtaining a comprehensive medical history is important, the initial interview should primarily focus on gathering information directly from the patient, as they can provide valuable insights about their experiences, concerns, and context that might not be captured in previous records.
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Correct Answer is D
Explanation
A. “Taking fluids poorly, but more than yesterday."
This assessment is vague (“taking fluids poorly”), lacks measurable details, and does not meet the clarity standard required in documentation.
B. "Apparently comfortable all night. Offers no complaints of pain."
“Apparently comfortable” is an assumption rather than an observable, objective statement, which could be legally questionable.
C. "Patient says she is still slightly nauseated, would like to try some toast and tea."
While this is clear, “slightly nauseated” could be more specific, and this does not objectively quantify the patient’s condition.
D. "4 cm reddened area over sacrum. Skin intact, warm, and dry."
This statement is concise, uses precise measurements, and includes objective data, meeting legal documentation guidelines.
Correct Answer is B
Explanation
A. Write down remarks on a clipboard to facilitate later topics of conversation.
Writing down remarks could distract from active listening and might make the patient feel as though the nurse isn’t fully engaged in the conversation.
B. Make a conscious effort to block out other sounds in the immediate environment.
Active listening requires focusing on the speaker by minimizing distractions, allowing the nurse to be fully attentive to the patient.
C. Maintain eye contact by staring at the patient.
Active listening involves natural eye contact, not staring, as staring can be intimidating and may cause discomfort for the patient.
D. Prompt the patient when the patient stops talking for a moment.
Giving the patient time to think and process without prompting respects their pace and encourages them to share more when ready.