A nurse is admitting a client who is 1 week postpartum and reports excessive vaginal bleeding. The nurse speaks a different language than the client. The client's partner and 10-year-old child are accompanying her. Which of the following actions should the nurse take to gather the client's admission data?

Allow the client's partner to translate.

Ask a nursing student who speaks the same language as the client to translate.

Have the client's child translate.

Request a female interpreter through the facility.

Answer and Explanation

The Correct Answer is D

A. Allow the client's partner to translate: Family members should not serve as interpreters due to concerns about accuracy, confidentiality, and potential bias in sensitive health information.

B. Ask a nursing student who speaks the same language as the client to translate: Using untrained personnel, including students, is discouraged because they may lack professional interpreting skills and could miscommunicate critical health information.

C. Have the client's child translate: Children are not appropriate interpreters due to their limited language skills, emotional immaturity, and potential to misinterpret medical information.

D. Request a female interpreter through the facility: A professional medical interpreter ensures accurate, confidential communication, respects cultural and gender preferences, and is the safest approach for gathering admission data, particularly regarding sensitive postpartum issues.

Nursing Test Bank

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Correct Answer is C

Explanation

Rationale:

A. A blister-like area: Blistering is not the expected reaction used to interpret a Mantoux test. The result is based on the presence and size of induration, not the formation of blisters.

B. A cool, blanched area: Coolness and blanching are not indicators of a positive test. These findings may reflect poor circulation or local skin reaction unrelated to tuberculosis screening.

C. An elevated, hardened area: Induration (elevated, firm area) at the injection site, measured in millimeters, is the basis for determining a positive result. The size threshold for positivity depends on the client’s risk factors for tuberculosis.

D. An area of ecchymosis: Bruising at the site is a local skin reaction that can occur after any injection and is unrelated to the diagnostic criteria for a positive Mantoux test.

A. Provide the client with high-calorie fluids every hour. B. Encourage the client to avoid napping during the day. C. Minimize environmental stimuli for the client. D. Weigh the client each day.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"}}

Explanation

Rationale:

Provide the client with high-calorie fluids every hour: The client has poor self-care, has not eaten for an extended period, and exhibits hyperactivity due to mania. Frequent high-calorie fluids help maintain hydration and meet increased metabolic demands. Regular intake supports nutrition and prevents further weight loss.
Encourage the client to avoid napping during the day: Avoiding daytime napping can help regulate sleep-wake cycles and promote restorative sleep at night. Clients experiencing mania often have decreased need for sleep, so reinforcing nighttime sleep routines supports stabilization of circadian rhythms.

Minimize environmental stimuli for the client: Clients experiencing a manic episode are easily overstimulated, which can worsen their agitation, anxiety, and psychosis. A calm, quiet environment with reduced distractions is essential for de-escalation and promoting rest.
Weigh the client each day: Daily weight monitoring helps assess nutritional status and detect fluid imbalance, which is important given the client’s poor self-care, hyperactivity, and potential for dehydration or rapid weight loss.

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Body System	Findings
Integumentary	Skin feels cool to the touch. Capillary refill 3 seconds in left foot Dressing on left hand shows small amount of moisture through gauze.
Vital Signs	Blood pressure 102/50 mm Hg Temperature 35.8° C (96.4° F) Respiratory rate 20/min
Genitourinary	Output of 25 mL dark amber urine through catheter

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who received a Mantoux skin test 72 hr ago for tuberculosis screening. Which of the following findings indicates a positive test result?

Correct Answer is C

Explanation

The nurse continues to care for the client. Exhibits A nurse on the inpatient mental health unit is planning care for the client. For each potential provider's prescription, click to specify if the prescription is anticipated or contraindicated for the client

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"}}

Explanation

A nurse is caring for a client who is 1 hr postpartum. Exhibits For each assessment finding, click to specify if the finding indicates the client's condition has improved or remains unchanged. There must be at least 1 selection in every row. There does not need to be a selection in every column.

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A nurse on a postpartum unit is caring for a client. Exhibits Drag words from the choices below to fill in each blank in the following sentence. The nurse should anticipate a provider's prescription for a(n)dropdown and dropdown.

A community health nurse is working with a family that is struggling to adapt following the loss of a family member. Which of the following actions should the nurse take first?