A nurse is assisting with the care of a client who needs an interpreter. Which of the following actions should the nurse take?

Direct questions to the interpreter.

Ask the client for regular feedback.

Incorporate acronyms into client teaching

Ask the client's family member to interpret.

Answer and Explanation

The Correct Answer is B

Rationale:

A. Direct questions to the interpreter: Communication should be directed to the client, not the interpreter. Speaking directly to the client fosters rapport and respects their autonomy, while the interpreter facilitates understanding.

B. Ask the client for regular feedback: Checking in frequently with the client ensures they understand the information being conveyed. This helps clarify misunderstandings and confirms effective communication through the interpreter.

C. Incorporate acronyms into client teaching: Using acronyms can confuse clients, especially those with limited English proficiency or unfamiliarity with medical terminology. Clear, simple language without jargon is preferred.

D. Ask the client's family member to interpret: Family members may lack medical terminology knowledge, may filter information, or breach confidentiality. Professional interpreters provide more accurate and unbiased communication.

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Correct Answer is D,C,B,A

Explanation

Rationale:

D. Inspection: This is always the first step in any physical assessment. The nurse observes the abdomen for contour, symmetry, skin condition, and any visible movements or abnormalities.

C. Auscultation: Performed before palpation to avoid altering bowel sounds. Listening to bowel and vascular sounds provides key information about gastrointestinal activity and blood flow.

B. Light palpation: Conducted next to assess for tenderness, guarding, and superficial masses. This helps ensure client comfort and provides a baseline before deeper pressure is applied.

A. Deep palpation: Done last to evaluate organ size, deep masses, or tenderness. It can stimulate peristalsis or discomfort, so it follows the less invasive steps to minimize changes to assessment findings.

A. Report of menstrual cycle B. Weight change C. Skin condition D. Neck exam E. Laboratory results F. Eye appearance

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

Explanation

Rationale:

• Report of menstrual cycle: The client’s last menstrual period was 3 months ago, indicating amenorrhea. This is commonly seen in hyperthyroidism due to hormonal imbalances that interfere with normal menstrual regulation.

• Weight change: She reports a 3-month history of unintentional weight loss with a good appetite, which reflects the increased metabolic rate typically caused by elevated thyroid hormone levels in hyperthyroidism.

• Skin condition: Her skin is described as warm and moist, which is consistent with hyperthyroidism. Excess thyroid hormone increases heat production and stimulates the sweat glands.

• Neck exam: The presence of a visible goiter suggests thyroid gland enlargement, often due to overstimulation by thyroid-stimulating immunoglobulins in autoimmune hyperthyroidism like Graves' disease. A goiter can occur in Hypothyroidism (e.g., Hashimoto's thyroiditis) as the gland tries to compensate. Therefore, this finding is consistent with both.

• Laboratory results: Elevated T3 (230 ng/dL), free T4 (3.4 ng/dL), and TSI (150%) confirm hyperthyroidism. These values exceed the normal range and strongly indicate an overactive thyroid gland.

• Eye appearance: Exophthalmos (protruding eyes) is observed, a hallmark of Graves’ disease. This autoimmune feature is linked exclusively to hyperthyroidism and is caused by inflammation and tissue buildup behind the eyes.

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A nurse is assisting with the care of a client who needs an interpreter. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to perform an abdominal examination for a client who has a gastrointestinal disease. Identify the order in which the nurse should use the examination techniques. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Correct Answer is D,C,B,A

Explanation

A nurse is assisting with the care of a client in a provider's clinic. Exhibits For each finding of the client, click to specify if the finding is consistent with Hyperthyroidism or Hypothyroidism. Each finding may support more than one disease process.

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

Explanation

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