A nurse is caring for a client who speaks a language different from the nurse. Which of the following actions should the nurse take?
Request an interpreter of a different sex from the client.
Request a family member or friend to interpret information for the client.
Direct attention toward the interpreter when speaking to the client.
Review the facility policy about the use of an interpreter.
The Correct Answer is D
A. Request an interpreter of a different sex from the client: The interpreter’s sex should ideally match the client’s preference for comfort and privacy, but this is not the first action. The priority is understanding facility policy and proper use of interpreters.
B. Request a family member or friend to interpret information for the client: Using family or friends can lead to miscommunication, breaches of confidentiality, or bias. Professional interpreters are preferred to ensure accurate and complete information.
C. Direct attention toward the interpreter when speaking to the client: When using an interpreter, the nurse should maintain eye contact and direct communication to the client, not the interpreter, to foster rapport and respect.
D. Review the facility policy about the use of an interpreter: Reviewing policy ensures that the nurse follows legal, ethical, and professional guidelines for language access services. This is the appropriate first action before arranging or using an interpreter.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Vaccinate susceptible children and adults against smallpox: Vaccination is a public health intervention but is typically conducted under the direction of public health authorities and is not a routine nursing disaster preparation activity.
B. Assess types, levels, and scopes of disasters: While understanding disaster types is important, assessment of scope and level is generally part of emergency management planning at an organizational or governmental level, rather than a direct nursing responsibility.
C. Make quarantine preparations for those exposed to anthrax: Quarantine planning is a public health measure implemented by authorities during an actual event. Nurses may assist in care during quarantine, but preparing quarantines is not a primary preparation activity.
D. Participate in community drills and mock events: Engaging in drills and simulations allows nurses to practice roles, improve response times, and enhance preparedness for real disaster situations. Participation in these exercises is a key nursing activity in disaster planning.
Correct Answer is ["A","B","D","E"]
Explanation
Rationale for correct choices:
- Skin turgor: Poor skin turgor indicates dehydration, which can lead to electrolyte imbalances, hypotension, and renal complications. Immediate assessment and fluid management are necessary to prevent further physiological deterioration.
- Heart rate: A heart rate of 120/min is tachycardic. This can be caused by dehydration, stimulant effects of mania, or other underlying medical issues. It requires prompt monitoring and intervention to prevent cardiovascular compromise.
- Sleep pattern: The client has not slept for 2 days, which increases the risk for physical exhaustion, worsening psychiatric symptoms, and impaired judgment. Sleep deprivation in the context of mania requires immediate attention to stabilize the client.
- Hallucinations: The client reports listening to unseen others, indicating auditory hallucinations. This can pose a risk for self-harm or unsafe behaviors, and immediate psychiatric assessment and intervention are warranted.
Rationale for incorrect choice:
- Hygiene: While the client’s hair and clothing are unclean, indicating self-care deficits, this is not an immediate threat to physiological stability. It is important for overall care planning but does not require urgent intervention compared to dehydration, tachycardia, sleep deprivation, or hallucinations.
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