A nurse is caring for a client with an allergic skin condition. The client develops wheezing, a swollen tongue, and hives. Which of the following is the nursing priority?

Assessing the client's neurologic status

Consulting an allergy specialist

Administering epinephrine

Determining the cause of the hives

Answer and Explanation

The Correct Answer is C

Administering epinephrine is the immediate priority when managing anaphylaxis. Epinephrine is the first-line treatment for anaphylaxis as it helps to rapidly reverse severe allergic symptoms, such as airway constriction, swelling, and hypotension.

A. While assessing the client's neurologic status is important for monitoring their overall condition, it may not be the immediate priority when the client is experiencing symptoms of an allergic reaction, particularly anaphylaxis.

B. While consulting an allergy specialist may be necessary for further evaluation and management of the client's allergic condition, it is not the immediate priority.

D. While determining the cause of the hives is important for identifying the allergen and preventing future allergic reactions, it is not the immediate priority during an acute episode of anaphylaxis.

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Correct Answer is C

Explanation

A. The nurse should speak directly to the client in the first person, even when using an interpreter. Speaking in the third person can create confusion and distance in communication.

B. This action demonstrates respect and engagement with the client, even though the nurse is using an interpreter. Eye contact can help to build rapport and ensure that the client feels heard and understood.
C. The interpreter should ideally sit beside or slightly behind the nurse, allowing the nurse and client to see each other while the interpreter translates. This setup fosters a more personal interaction between the nurse and the client.
D. Using long sentences can make it difficult for the interpreter to accurately translate the message.

A. "Do you have family who can help you when you get home?" B. "Has anything stressful happened recently?" C. "You really do need to stop smoking: your kids need you." D. How would you describe your feelings about the procedure?

Correct Answer is ["A","B","D"]

Explanation

A. This statement is non-judgmental. It focuses on assessing the patient's support system and potential resources for assistance after surgery without implying any judgment about the patient's circumstances.
B. This statement is non-judgmental. It aims to assess the patient's current stressors or life events that may impact her emotional well-being and coping abilities without implying any judgment.
C. This statement is judgmental. It conveys a directive and implies criticism or disapproval of the patient's smoking habit. It may also imply blame for the patient's health condition, which can be counterproductive and may cause the patient to feel defensive or discouraged.
D. This statement is non-judgmental. It encourages the patient to express her thoughts and emotions about the upcoming procedure without imposing any judgment or criticism.

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A nurse is caring for a client with an allergic skin condition. The client develops wheezing, a swollen tongue, and hives. Which of the following is the nursing priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is using a medical interpreter to communicate with a client. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A 35-year-old woman has been admitted to the hospital for a hysterectomy secondary to uterine cancer caused by smoking, and the nurse is collecting subjective data prior to surgery. Which statements by the nurse could be construed as non-judgmental? (Select All that Apply.)

Correct Answer is ["A","B","D"]

Explanation

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