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

Answer and Explanation

The Correct Answer is D

A. Request an interpreter of a different sex from the client. The interpreter's sex should be based on the client’s cultural preferences, not assumed by the nurse. This decision should be made to promote comfort and cultural sensitivity.
B. Request a family member or friend to interpret information for the client. This is not recommended, especially for medical discussions, as it may lead to misinterpretation, breaches of confidentiality, and biased communication.
C. Direct attention toward the interpreter when speaking to the client. The nurse should speak directly to the client, not the interpreter, to maintain a therapeutic relationship and respect for the client.
D. Review the facility policy about the use of an interpreter. This is the most appropriate initial action. Each facility typically has specific guidelines and procedures for accessing qualified medical interpreters, which the nurse should follow to ensure accurate and ethical communication.

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Correct Answer is ["A","B","C","D","E","F","G","H"]

Explanation

Client reports feeling unwell: This is clinically significant when combined with fever, foul-smelling lochia, and elevated WBCs; it could indicate systemic infection such as endometritis.
Fundus boggy but firms with massage: Indicates uterine atony, a risk factor for postpartum hemorrhage. Even if it responds to massage, repeated bogginess suggests the need for uterotonic medications and close monitoring.
Foul-smelling, dark brown lochia: These findings are highly suggestive of uterine infection (endometritis), especially when paired with uterine tenderness, fever, and elevated WBCs.
WBC count 33,000/mm³: Severely elevated — well above normal postpartum leukocytosis (typically up to 20,000/mm³). A level of 33,000 strongly suggests an ongoing infectious process.
Temperature 38.2°C (100.8°F): Slightly elevated, and while low-grade fever is common postpartum, when associated with uterine tenderness and abnormal lochia, it raises concern for infection and should be monitored and managed appropriately.
Lung sounds diminished in the bases: Could be due to post-surgical hypoventilation, immobility, or atelectasis. Should prompt encouragement of deep breathing, incentive spirometry, and ambulation.
No bowel movement since birth, hypoactive bowel sounds: This is a common post-cesarean finding due to anesthesia and immobility, but it still indicates delayed return of GI function and should be monitored for signs of ileus.

A. Rotate staff members caring for the client. B. Speak in a neutral tone when addressing the client. C. Limit the client's opportunities to socialize with others. D. Mix the medication with the client's food items.

Correct Answer is B

Explanation

A. Rotate staff members caring for the client. Clients with paranoid personality disorder often struggle with mistrust and feel suspicious of others. Consistency in staffing is important to build rapport and reduce anxiety, so rotating staff can worsen paranoia.
B. Speak in a neutral tone when addressing the client. This is appropriate because a calm, neutral, and non-threatening tone helps reduce perceived threats or suspicion. It promotes a sense of safety and control, which is important for therapeutic communication with paranoid individuals.
C. Limit the client's opportunities to socialize with others. While clients with paranoid personality disorder may prefer limited interaction, completely restricting socialization can increase isolation and reinforce delusional thinking. Structured, safe interactions are often encouraged.
D. Mix the medication with the client's food items. Administering medication without the client’s knowledge is deceptive and unethical, especially in someone already prone to distrust. Open and honest communication about treatment is crucial for promoting cooperation and trust.

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A nurse is caring for a client who speaks a language different from the nurse. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["A","B","C","D","E","F","G","H"]

Explanation

A nurse is creating a plan of care for a client who has paranoid personality disorder and refuses to take their medication. Which of the following interventions should the nurse include in the plan?

Correct Answer is B

Explanation

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