A client who is deaf and communicates using sign language is being admitted by a nurse who does not know sign language. Which of the following actions should the nurse take?
Obtain a board that uses colored pictures as communication.
Request an interpreter during the initial assessment.
Familiarize themselves with commonly used signed language.
Ask a family member to be present during the admission.
The Correct Answer is B
A) Using a communication board with colored pictures might not effectively facilitate communication for someone who primarily uses sign language.
B) Requesting an interpreter during the initial assessment ensures effective communication between the nurse and the client.
C) Familiarizing themselves with commonly used signed language may help the nurse in the long term but may not be feasible or effective during the immediate admission process.
D) Asking a family member to be present during the admission may help but may not provide the necessary communication support for effective assessment and care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C"}
Explanation
The client's pain level should be addressed first based on the principle of prioritizing interventions according to the client's immediate needs and potential severity of the condition. Chest pain, especially when radiating to the left arm, is a concerning symptom that can indicate myocardial ischemia or infarction. It is essential to promptly assess and manage the client's pain to provide relief and potentially mitigate further cardiac damage. In this scenario, the client rates the pain as 7 out of 10, indicating moderate to severe discomfort, which warrants immediate attention.
After addressing the client's pain level, the nurse should focus on the client's ECG results. The ECG findings of tachycardia with ST segment elevation and T wave changes are indicative of myocardial ischemia or infarction. These changes suggest ongoing myocardial damage and require further evaluation and intervention. The ECG results provide crucial information about the client's cardiac status and guide subsequent treatment decisions, such as initiating interventions to restore myocardial perfusion or preparing for invasive procedures like cardiac catheterization.
Correct Answer is A
Explanation
A. A palpable thrill over the graft site indicates adequate blood flow through the graft.
B. The presence of a bruit (a humming sound) over the graft site is expected and indicates blood flow.
C. Normotensive blood pressure is not specifically indicative of the circulation of the graft.
D. A dilated appearance of the graft may indicate an issue with the graft, such as an aneurysm, rather than adequate circulation.
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