An older client comes to the clinic with a family member. When the nurse attempts to take the client's health history, the client does not respond to questions in a clear manner. Which action should the nurse implement first?
Provide a printed health care assessment form.
Defer the health history until the client is less anxious.
Ask the family member to answer the questions.
Assess the surroundings for noise and distractions.
The Correct Answer is D
The ability to effectively communicate and provide accurate information can be impacted by external factors such as noise, distractions, or an unfamiliar environment. By assessing the surroundings, the nurse can identify and address any potential barriers to communication.
Once the nurse has addressed any environmental factors that may be hindering communication, they can proceed with other strategies to facilitate the health history assessment. This may include providing a printed healthcare assessment form to assist the client in organizing their thoughts or deferring the assessment until the client is less anxious.
Asking the family member to answer the questions should be considered if the client is unable to provide accurate information or is cognitively impaired. However, it is important to first address any environmental factors and attempt to engage the client directly in the assessment process.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"B"}}
Explanation
A. Understanding: The client recognizes that taking allergy medications before the hike might have helped prevent an exacerbation.
B. No understanding: The client doesn't realize that eating a snack could impact asthma symptoms. Proper education is needed here.
C. Understanding: The client acknowledges that exposure to cigarette smoke during the hike could have contributed to the exacerbation.
D. Understanding: The client identifies that stress management could be important in preventing asthma exacerbations.
E. No understanding: The client is not aware that taking an extra dose of Fluticasone-Salmeterol could have been beneficial. Further education is necessary.
Correct Answer is ["D","E"]
Explanation
A) Incorrect - Phototherapy, often used to treat conditions like seasonal affective disorder (SAD) or certain skin conditions, involves exposure to specific wavelengths of light. It is not typically used as a treatment for distressing thoughts and memories related to trauma, as described in the client's situation.
B) Incorrect - Lithium is primarily used to treat bipolar disorder and is not a first-line treatment for trauma-related symptoms or acute stress disorder. The client's symptoms are more indicative of trauma-related distress, which would be addressed through psychotherapeutic approaches like cognitive behavioral therapy (CBT).
C) Incorrect - "Consciousness-raising" is not a recognized treatment intervention in this context.
It's important to focus on evidence-based therapeutic approaches for trauma-related symptoms, such as psychotherapy and support services.
D) Correct - Cognitive behavioral therapy (CBT) is Given the client's distressing thoughts and memories, CBT is a highly effective psychotherapy approach. It focuses on identifying and modifying negative thought patterns and behaviors associated with trauma. CBT can help the client develop healthier coping strategies.
E) Correct - Animal-assisted therapy involves interacting with trained animals to improve emotional well-being. Since the client expresses feeling unhappy and having difficulty coping, animal therapy can provide comfort, reduce stress, and promote a sense of companionship.
F) Incorrect - Electroconvulsive therapy (ECT) is a treatment primarily used for severe cases of depression or certain psychiatric conditions that are unresponsive to other treatments. It involves inducing controlled seizures to affect brain chemistry. ECT is not a first-line treatment for the client's distressing thoughts and memories following a traumatic event.
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