A nurse is assigned to perform the assessment interview for a 65-year-old woman brought to the hospital emergency department by her 16-year-old granddaughter, who found her wandering around the yard of her suburban home, saying "I can't find my way home.". The nurse finds the client to be so profoundly confused that she is unable to respond to or answer any questions posed. In this case the nurse should
a. persevere and record the client's answers to questions on the agency assessment form.
b. document the client's confusion and obtain as much data as possible from the granddaughter.
c. ask a more experienced nurse to perform the interview.
d. call for a mental health advocate to support the client's rights.
ANS: B
When the client (primary source) is unable to provide information, secondary sources should be
used, in this case the granddaughter. Later, more data may be obtained from other relatives or
neighbors who are familiar with the client. Option C: An experienced nurse would probably do no
better. Option D is unnecessary.
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