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 B
Explanation
Rationale:
A. Abdominal pain: While abdominal pain can occur with peritonitis, it often develops after the initial changes in the dialysate effluent. Pain may also be related to catheter placement or dialysate temperature, so it is not the earliest definitive indicator.
B. Cloudy effluent: Cloudy dialysate is typically the first and most reliable sign of peritonitis in clients receiving peritoneal dialysis. It indicates the presence of white blood cells and infection in the peritoneal cavity before systemic symptoms appear.
C. Nausea: Nausea may occur later as part of the systemic inflammatory response, but it is nonspecific and can be caused by multiple factors, including the dialysis process itself or other gastrointestinal disturbances.
D. Fever: Fever is a later manifestation of peritonitis, often developing after local signs are present. It indicates systemic involvement and immune activation but is not the earliest detectable change.
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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