The nurse is setting up the physical environment for an interview with a client and plans to obtain subjective data regarding the client's health.Which interventions are appropriate? Select three options that apply.
Ensure comfortable seating at eye level for the client and nurse.
Provide seating for the client so that the client faces a strong light.
Ensure that the distance between the client and nurse is at least 7 ft (2.1 meters).
Place a chair for the client across from the nurse's desk.
Set the room temperature at a comfortable level.
Remove distracting objects from the interviewing area.
Correct Answer : A,E,F
A. Ensure comfortable seating at eye level for the client and nurse: Establishes a non-intimidating environment, helping the client feel more at ease.
B. Provide seating for the client so that the client faces a strong light: Incorrect; this may cause discomfort and make the client feel scrutinized.
C. Ensure that the distance between the client and nurse is at least 7 ft: Too great a distance for effective communication; ideal distance is 3-4 feet.
D. Place a chair for the client across from the nurse's desk: Creates a formal, potentially intimidating setting, discouraging openness.
E. Set the room temperature at a comfortable level: Ensures physical comfort, aiding in client relaxation and openness.
F. Remove distracting objects from the interviewing area: Minimizes potential distractions, keeping the client focused and the environment conducive to communication.
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Correct Answer is B
Explanation
A. Intake and output: Although helpful, intake and output measurements can sometimes be inaccurate, as not all fluid retention may be recorded.
B. Daily weight: Daily weight measurements are the most reliable way to assess fluid retention because changes in body weight accurately reflect gains or losses in body fluid, especially in clients with chronic kidney disease.
C. Sodium level: Sodium levels can indicate fluid imbalances, but they do not directly measure fluid volume excess.
D. Skin tenting: Skin tenting is used to assess dehydration, not fluid retention, and is not a reliable measure in chronic kidney disease.
Correct Answer is A
Explanation
A. The client on peritoneal dialysis who is reporting a hard and rigid abdomen. A hard, rigid abdomen suggests peritonitis, a life-threatening complication requiring immediate assessment and intervention.
B. The client who does not have a palpable thrill or auscultated bruit: This indicates a possible vascular access issue, but it is not as immediately life-threatening as peritonitis.
C. The client who is reporting a 3.6 kg weight gain and refusing dialysis: This weight gain could signal fluid overload, but refusal of dialysis would require a different approach that may not need immediate intervention unless symptoms worsen.
D. The client with a hemoglobin of 9.0 mg/dL and hematocrit of 26%: This low hemoglobin and hematocrit level may require treatment, but it is not an immediate life-threatening issue like peritonitis.