An older adult patient has been prescribed warfarin (coumadin). The nurses primary intervention involves daily review of the patient's:

A. Reflex tone refers to the neurological response of the body to stimuli and is not directly related to the action or monitoring of anticoagulant therapy. While assessing reflexes might be important for overall patient health, it is not specifically relevant to monitoring the effects of warfarin. Reflex tone does not provide information on the anticoagulation status or risk of bleeding associated with warfarin therapy.
B. Checking the body for bruising helps assess the safety of warfarin therapy and may indicate the need for dosage adjustments or further investigation if bruising is excessive. However, while monitoring for bruising is essential, it is not the primary method for assessing the effectiveness and safety of anticoagulant therapy.
C. While monitoring kidney function is relevant for overall medication management, it is not the primary focus for directly assessing the effectiveness or safety of warfarin therapy. Kidney function is more related to adjusting doses and avoiding potential complications.
D. Regularly reviewing PT is crucial for managing warfarin therapy because it directly reflects the anticoagulation effect of the medication. The International Normalized Ratio (INR), derived from PT, is used to ensure the patient is within the therapeutic range for effective anticoagulation while minimizing the risk of bleeding.

A. While ensuring confidentiality is crucial for building trust and encouraging openness, it is often a standard assurance given after establishing a rapport. It does not directly address immediate comfort or the setting of the interview, which can have a significant impact on the patient’s initial anxiety.
B. Explaining the reason for asking questions can help the patient understand the purpose of the interview, making them feel more comfortable and less anxious. This can also help in building trust and encouraging the patient to provide more accurate and complete information. However, this explanation usually comes after ensuring that the interview environment is comfortable and private.
C. Creating a comfortable and private environment is a critical first step. A well-arranged and private interview area helps to make the patient feel safe and at ease, reducing their anxiety and enabling them to speak more freely. It sets the stage for a more successful and effective interview.
D. Allowing the patient to ask questions about the interview can be beneficial and may help in reducing anxiety. It provides an opportunity to clarify any uncertainties the patient might have. However, this step is usually more effective after addressing the immediate comfort and privacy concerns of the interview setting.