A nurse in a mobile health clinic is caring for a client who requires a tetanus immunization and is accompanied by his daughter. The client does not speak the same language as the nurse. Which of the following actions should the nurse take?
Have the client's daughter communicate information about the procedure.
Arrange for a member of the client's community to interpret the teaching.
Identify the client's spoken dialect prior to contacting an interpreter.
Use professional terminology when providing education prior to the procedure.
The Correct Answer is C
Choice A reason: Having the client's daughter communicate information about the procedure is not an action that the nurse should take. The daughter may not be a reliable or accurate interpreter, as she may have limited language skills, lack medical knowledge, or be influenced by her emotions or biases. The nurse should use a qualified interpreter who can ensure the confidentiality, accuracy, and completeness of the communication.
Choice B reason: Arranging for a member of the client's community to interpret the teaching is not an action that the nurse should take. The member of the client's community may not be a qualified or impartial interpreter, as he or she may have a personal or professional relationship with the client, or may have a conflict of interest or a hidden agenda. The nurse should use a professional interpreter who can maintain the boundaries, objectivity, and neutrality of the communication.
Choice C reason: Identifying the client's spoken dialect prior to contacting an interpreter is an action that the nurse should take. This will help the nurse to find an appropriate interpreter who can communicate effectively and respectfully with the client. The nurse should also consider the client's cultural background, preferences, and needs when selecting an interpreter.
Choice D reason: Using professional terminology when providing education prior to the procedure is not an action that the nurse should take. The nurse should use simple and clear language that the client can understand, and avoid using jargon, slang, or idioms that may confuse or offend the client. The nurse should also check the client's comprehension and ask for feedback throughout the communication.
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Related Questions
Correct Answer is C
Explanation
Choice A reason: The client dressing her affected side first is not a finding that the nurse should report to the interprofessional care team, as it indicates that the client is following the proper technique for dressing after a stroke. Dressing the affected side first helps the client maintain range of motion and prevent contractures of the affected limbs.
Choice B reason: The client bearing weight on their arms when using crutches is not a finding that the nurse should report to the interprofessional care team, as it is a normal and expected way of using crutches. Bearing weight on the arms helps the client balance and support their body weight while walking with crutches.
Choice C reason: The client coughing when swallowing her medications is a finding that the nurse should report to the interprofessional care team, as it indicates that the client may have dysphagia, or difficulty swallowing, which is a common complication of stroke. Dysphagia can increase the risk of aspiration, pneumonia, dehydration, and malnutrition. The nurse should assess the client's swallowing ability and refer them to a speech-language pathologist for further evaluation and intervention.
Choice D reason: The client's caregiver filling a pill organizer weekly is not a finding that the nurse should report to the interprofessional care team, as it is a positive and helpful way of managing the client's medications. Filling a pill organizer weekly can help the client and the caregiver remember the medication names, doses, and schedules, and prevent medication errors or omissions.
Correct Answer is D
Explanation
Choice A reason: A client who has superficial partial-thickness burn injuries over 5% of his body is not the highest priority for treatment. This type of burn injury affects only the epidermis and the upper layer of the dermis, and causes pain, redness, and blisters. The client may need fluid replacement, pain management, and wound care, but is not in immediate danger of life-threatening complications.
Choice B reason: A client who has a femur fracture with a 2+ pedal pulse is not the highest priority for treatment. This type of fracture involves the breakage of the thigh bone, which is the largest and strongest bone in the body. The client may experience severe pain, swelling, deformity, and bleeding. A 2+ pedal pulse indicates that the blood flow to the lower extremity is adequate, but not optimal. The client may need immobilization, traction, surgery, and infection prevention, but is not in immediate danger of life-threatening complications.
Choice C reason: A client who is ambulatory and exhibits manic behavior is not the highest priority for treatment. This type of behavior involves a state of elevated mood, energy, and activity, which may be caused by stress, trauma, or a mental disorder. The client may experience euphoria, irritability, impulsivity, and poor judgment. The client may need psychological support, medication, and safety measures, but is not in immediate danger of life-threatening complications.
Choice D reason: A client who has a rigid abdomen with manifestations of shock is the highest priority for treatment. This type of condition involves a severe injury to the abdominal organs, such as the liver, spleen, or intestines, which may cause internal bleeding, inflammation, and infection. The client may experience pain, tenderness, distension, and guarding of the abdomen, as well as signs of shock, such as hypotension, tachycardia, pallor, and confusion. The client may need fluid resuscitation, blood transfusion, surgery, and antibiotics, and is in immediate danger of life-threatening complications.
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