A nurse assesses an older adult patient brought to the emergency department by a family member. The patient was wandering outside saying, "I can't find my way home." The patient is confused and unable to answer questions. Select the nurse's best action.

A) Record the patient's answers to questions on the nursing assessment form.
B) Ask an advanced practice nurse to perform the assessment interview.
C) Call for a mental health advocate to maintain the patient's rights.
D) Obtain important information from the family member.

Question

Daksh Chauhan · Accepted Answer

Final Answer : D, Explanation :  When the patient (primary source) is unable to provide information, secondary sources should be used, in this case, the family member. Later, more data may be obtained from other information sources familiar with the patient. An advanced practice nurse is not needed for this assessment; it is within the scope of practice of the staff nurse. Calling a mental health advocate is unnecessary. See relationship to audience response question.

Definitions

Learning Objectives

Learning Objectives

Related questions