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 A
Explanation
A. "What bothers you most about the idea of giving yourself an injection?" This open-ended question allows the patient to express specific fears or concerns, facilitating a deeper conversation to address the patient’s worries.
B. "Everyone feels like that at first. You'll get over it." This response is dismissive and may invalidate the patient’s feelings by suggesting that their concern is typical rather than unique.
C. “I know just how you feel. I would have trouble giving myself an injection." While empathetic, this response shifts focus to the nurse’s feelings rather than exploring the patient’s specific concerns.
D. "Don't be afraid. It's an easy skill for anyone to learn." This response minimizes the patient’s fear and could make them feel dismissed rather than supported.