A nurse is developing the plan of care for a client who does not speak the same language as the nurse. Which of the following interventions should the nurse include?

Determine the client's level of fluency in his primary language.

Encourage the client to nod to indicate understanding.

Speak directly to the interpreter when teaching the client.

Make sure a family member is present to interpret for the staff.

Answer and Explanation

The Correct Answer is A

This is important because it allows the nurse to assess the client's ability to communicate in their primary language. Knowing the client's level of fluency helps the nurse determine the most effective communication strategies and whether an interpreter is necessary.

B. While nodding can be a form of nonverbal communication indicating understanding, relying solely on this may not accurately gauge the client's comprehension.

C. Even in the presence of n interpreter, the nurse should speak directly to the client.

D. Family members may not be proficient in both languages or may not accurately convey medical information.

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Correct Answer is A

Explanation

A Close friend may provide warm feeling of support due to their background knowledge of the client. It gives the client a sense of belonging and support.

B Social workers are trained to provide crisis intervention, advocacy, and support services tailored to the needs of survivors of sexual assault. However, thery might not be able to connect closely with the client like a close friend.
C. Chaplains may offer emotional and spiritual support to individuals in crisis situations, including survivors of sexual assault but are not trained to handle such cases.
D. While their expertise is valuable for long-term therapy and support, they may not be readily available for immediate crisis intervention in the emergency department.

A. The client was administered epinephrine. B. The client experienced a biphasic reaction. C. The client required the administration of glucagon in addition to epinephrine. D. The client does not know what triggered the reaction.

Correct Answer is D

Explanation

Not knowing what triggered the allergic reaction is a significant concern and may indicate a need for allergy testing and evaluation by an allergy specialist. Identifying the trigger allergen is crucial for implementing avoidance strategies, preventing future allergic reactions, and managing the client's overall health and well-being.
A. While the administration of epinephrine indicates the severity of the allergic reaction and the need for immediate treatment, it may not be the most important indication for referral to an allergy specialist on its own.
B. A biphasic reaction refers to the recurrence of symptoms after an initial resolution of an allergic reaction. Biphasic reactions can occur within hours or days after the initial reaction and can be severe or even life-threatening. This, however, does not necessitate need for a specialist.
C. While severe hypoglycemia can occur in some cases of anaphylaxis, it may not be the primary indication for referral to an allergy specialist.

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A nurse is developing the plan of care for a client who does not speak the same language as the nurse. Which of the following interventions should the nurse include?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

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Correct Answer is D

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