A nurse is about to interview an older client whose glasses and hearing aid were placed in the bedside drawer for safe keeping.
Before beginning the interview, which nursing intervention will best facilitate data collection?
Give the client her glasses and hearing aid.
Assist the client in putting on glasses and hearing aid.
Ask the client if she needs her glasses and hearing aid.
Explain the interview process clearly before speaking.
The Correct Answer is B
Choice A rationale
Merely giving the client her sensory aids does not ensure they are used; a client may need physical assistance due to limited dexterity or cognitive impairment. The nurse's responsibility is to optimize the client's functional capacity for the interview, which requires ensuring the aids are correctly in place to maximize the ability to see and hear.
Choice B rationale
Assisting the client to put on her glasses and hearing aid directly addresses the potential barrier to communication and data collection. Optimal vision and hearing are essential for an older adult to accurately perceive and process verbal and nonverbal communication, thereby facilitating rapport, trust, and comprehensive, accurate assessment data collection.
Choice C rationale
Asking the client if she needs her aids, although respectful, is insufficient because the nurse already knows the aids are in the drawer. Furthermore, the client may decline due to embarrassment or confusion. The nurse's proactive, assistive approach is necessary to ensure optimal sensory function for an effective interview.
Choice D rationale
Explaining the interview process clearly is a standard communication technique, but it won't resolve the underlying sensory deficits. Even with a clear explanation, a client with uncorrected hearing and vision loss will likely miss important verbal and nonverbal cues, leading to miscommunication and compromised data reliability. Sensory correction is foundational.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Serotonin 5HT_2 receptors are targeted by many atypical antipsychotics and mood stabilizers. Blocking these receptors is associated with desired effects like improved mood and reduced psychosis, but also with side effects like weight gain or hypotension. It is not the primary mechanism responsible for dry mouth, constipation, and blurred vision, which are characteristic anticholinergic effects.
Choice B rationale
Acetylcholine (ACh) receptors, specifically muscarinic receptors, are blocked by many psychotropic drugs, especially older antidepressants and antipsychotics. This anticholinergic action inhibits parasympathetic nervous system responses, leading to the classic peripheral side effects: dry mouth (xerostomia), constipation (decreased peristalsis), and blurred vision (mydriasis/cycloplegia), which are directly mediated by ACh blockade.
Choice C rationale
Alpha-1 (α_1) adrenergic receptors are blocked by many psychotropic agents, especially antipsychotics. Blocking these receptors causes vasodilation and is primarily associated with orthostatic hypotension (dizziness upon standing) and reflex tachycardia. While it may sometimes contribute to overall side effect burden, it is not the direct cause of the triad of dry mouth, constipation, and blurred vision.
Choice D rationale
Histamine (H_1) receptors are blocked by many psychotropic drugs, particularly those with sedative properties. This blockade primarily leads to side effects such as sedation, drowsiness, and weight gain. While it contributes to the overall side effect profile, it is not the main pharmacological mechanism responsible for the distinct cluster of dry mouth, constipation, and blurred vision symptoms.
Correct Answer is B
Explanation
Choice A rationale
Interpersonal therapy (IPT) focuses on current interpersonal relationships and related issues like grief, role disputes, or social deficits. While the client's issue is relational, the core concern about being "too possessive" suggests an underlying, often unconscious, pattern of relating rooted in past experiences, which is better suited to psychodynamic exploration.
Choice B rationale
Psychodynamic therapy is the most suitable approach because it explores how early childhood experiences and unconscious processes (like transference and defense mechanisms) influence current relationship patterns and emotional conflicts. Possessiveness is often viewed as a maladaptive defense against deeper fears of abandonment, making an exploration of these historical roots essential.
Choice C rationale
Cognitive Behavioral Therapy (CBT) is highly effective for modifying distorted thought patterns and specific maladaptive behaviors (e.g., compulsions). While CBT could address the behavior of possessiveness, it might not fully explore the root emotional and developmental basis of the possessive tendency, which is crucial for lasting change in relationship dynamics.
Choice D rationale
Dialectical Behavior Therapy (DBT) is primarily designed for individuals with severe emotion dysregulation and impulsive behaviors, often associated with Borderline Personality Disorder. While it teaches valuable skills in mindfulness and distress tolerance, it is generally considered overly specialized for the possessiveness issue described without evidence of pervasive instability or severe self-harm.
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