The nurse is preparing to interview the older adult client and perform a head-to-toe assessment. Which of the following actions by the nurse indicate the nurse requires further education? Standard Text: Select all that apply
1. The nurse has requested that the client put on a cotton gown prior to the interview.
2. The nurse seats the client so that the light from the window faces the client with the nurse's back to the window.
3. The nurse addresses the client by her first name.
4. The nurse maintains eye contact; both nurse and client are seated.
5. During the interview, the nurse asks if the client is currently experiencing any pain or anxiety before proceeding further.
1,2,3
Rationale 1: The nurse has requested that the client put on a cotton gown prior to the interview. Thin cotton examining gowns often make the older client feel uncomfortably chilly and less able to attend to the health history questions. The nurse could provide the client with a robe or wait to request that the client put on a robe until following the interview.
Rationale 2: The nurse seats the client so that the light from the window faces the client with the nurse's back to the window. The client should have her back to the window or strong light source. Thus glare is reduced, and the light falls upon the face of the examiner.
Rationale 3: The nurse addresses the client by her first name. The nurse should address the client by her last name until the client states that it is appropriate to be more informal.
Rationale 4: The nurse maintains eye contact; both nurse and client are seated. The nurse should maintain good eye contact during the interview and assessment. The nurse and client should be able to communicate at eye level.
Rationale 5: During the interview, the nurse asks if the client is currently experiencing any pain or anxiety before proceeding further. The nurse should assess the client's level of pain and anxiety to ensure that the client does not require pain medication or an intervention prior to continuing with the interview and assessment.
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