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 A
Explanation
Choice A rationale
Resilience is the dynamic process encompassing positive adaptation and the ability to maintain mental and physical well-being despite experiencing adversity or stress. This statement demonstrates the core tenets of resilience: acknowledging the stressor ("Losing my job was hard") and expressing self-efficacy and a proactive approach to recovery by utilizing existing resources and capabilities ("my skills will help me get another one").
Choice B rationale
This statement reflects hopelessness and pessimism, characterized by a fixed negative outlook on future health despite intervention. Resilience involves maintaining optimism and the expectation of a positive eventual outcome even during hardship, which is directly contradicted by this statement's absolute belief in permanent poor health.
Choice C rationale
This statement illustrates a dependence on others for essential life tasks during a crisis, indicating a lack of resilience or a temporary decompensation under stress. While understandable, resilience involves the ability to manage and function autonomously or to marshal one's own resources to cope with significant loss.
Choice D rationale
This statement is an expression of altruism or parental sacrifice and does not directly relate to the individual's ability to bounce back from personal adversity. Resilience focuses on the self's capacity to adapt and overcome challenges, not on the prioritization of another's well-being over one's own needs or desires.
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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