A nurse is teaching the staff about a nursing theory that views a person, family, or community developing a normal line of defense. Which theory is the nurse describing?

Choice A reason: Asking the family about normal behavior provides subjective context but lacks standardized cognitive assessment. Cognitive function requires objective tools like the MMSE to evaluate memory, orientation, and attention. Relying solely on family input risks missing subtle deficits, delaying diagnosis of conditions like dementia or delirium critical for patient management.

Choice B reason: Asking for name, location, and month tests orientation, a component of cognitive assessment, but is too limited. The MMSE offers a comprehensive evaluation of memory, language, and visuospatial skills. This narrow approach risks overlooking broader cognitive impairments, potentially missing early dementia or other neurological conditions requiring targeted interventions.

Choice C reason: The HHIE-S assesses hearing impairment, not cognitive function. Hearing loss may affect communication but isn’t a direct cognitive measure. Using this tool for cognition misdirects assessment, risking failure to identify cognitive deficits like memory loss, delaying diagnosis and management of conditions such as Alzheimer’s disease or acute confusional states.

Choice D reason: Administering the MMSE is a standardized, comprehensive tool to assess cognitive function, evaluating orientation, memory, attention, language, and visuospatial skills. It detects impairments in conditions like dementia or delirium, guiding diagnosis and treatment. Its structured approach ensures reliable identification of cognitive deficits, critical for planning care and interventions in clinical settings.

Choice A reason: Caring touch involves physical contact to convey empathy, like holding a hand. The nurse leaves the room without touching the patient or family, overwhelmed by grief. This action does not involve physical contact or comfort, making it unrelated to caring touch in this scenario.

Choice B reason: Therapeutic touch is a healing technique using energy fields, not applicable here. The nurse’s departure due to emotional overwhelm does not involve physical or energetic interaction with the family or patient, focusing instead on self-preservation, making this an incorrect type of touch.

Choice C reason: Task-oriented touch involves physical contact for procedures, like taking a pulse. The nurse’s action of leaving the room is not task-related or physical. It reflects an emotional response to grief, not a clinical task, making this an incorrect description of the nurse’s behavior.

Choice D reason: Protective touch describes actions to shield oneself or others from emotional distress, like withdrawing from overwhelming situations. The nurse, overwhelmed by the family’s grief, leaves the room to cope, demonstrating protective touch by prioritizing emotional self-preservation, making this the correct description.