A nurse is observed conducting an assessment interview for a newly adm

A nurse is observed conducting an assessment interview for a newly admitted client. Which of the following would require immediate follow-up by the nurse’s mentor?

1. Conducting the interview with the client’s boyfriend present
2. Stopping the interview to answer a page from the nursing station
3. Frequently checking the time while waiting for the client to answer
4. Heard asking the client, “Am I correct; you’ve rated your pain a 9 out of 10?”

ANSWER

ANS: 3
Clients are less likely to fully reveal the nature of their health care problems when nurses show little interest, appear rushed, or are easily distracted by activities around them. As long as the nurse had the client’s permission, this would not require follow-up. While interrupting an assess-ment is not recommended, a page is an example of an acceptable exception and so this would not require follow-up. If the nurse were confirming the information, it would not require follow-up. If the mentor felt the nurse was questioning the validity of client’s pain rating, a follow-up would be appropriate because a client’s pain rating should not be questioned.