A nurse is reinforcing discharge instructions with a client who speaks a different language than the nurse. Which of the following actions should the nurse document in the client's medical record to ensure the language needs are met?

Nurse addressing the client directly while the interpreter is present.

Nurse asking the client for questions at the end of the instructions.

Staff member serving as an interpreter for the client.

Family member acting as an interpreter for the client.

Answer and Explanation

The Correct Answer is A

Rationale:

A. Nurse addressing the client directly while the interpreter is present: This demonstrates culturally competent and client-centered care. Documenting that the nurse communicated directly with the client through a qualified interpreter shows appropriate use of interpretation services and respect for the client's autonomy.

B. Nurse asking the client for questions at the end of the instructions: While this is good practice, it does not specifically demonstrate that the client's language needs were addressed. Without interpreter documentation there’s no assurance the client understood the information.

C. Staff member serving as an interpreter for the client: Unless the staff member is a certified medical interpreter, using them for interpretation may result in miscommunication and is not best practice. Documentation should reflect use of trained professionals.

D. Family member acting as an interpreter for the client: Family members should not be used for interpretation due to risks of bias, inaccuracies, and privacy violations. Professional interpreters are necessary to ensure accurate, safe, and confidential communication.

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Correct Answer is B

Explanation

Rationale:

A. The client's next dressing change is scheduled in 4 hr.: This is routine scheduling information that does not require input from the entire interprofessional team. It is more relevant for shift handoff or task tracking than for collaborative care planning.

B. The client has developed difficulty ambulating: New or worsening mobility issues can impact the client’s safety, rehabilitation needs, discharge planning, and therapy referrals. This information is essential for all members of the interprofessional team, including physical therapists and case managers.

C. The client's vital signs are checked every 8 hr.: This detail reflects standard monitoring protocol and does not provide meaningful insight into the client’s current health status or changes that would impact team planning or intervention.

D. The client has state-sponsored health insurance: While insurance type may influence discharge or equipment planning, it is handled by social services or case management. It is not the most relevant information to bring forward in a clinical team meeting.

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"D"}

Explanation

Rationale:
• Compartment syndrome: Casts can restrict swelling, increasing pressure within the compartment. Moderate toe edema and capillary refill slowing from brisk to 3 seconds are warning signs. Without prompt intervention, tissue perfusion may decline, leading to ischemia.

• Edema of toes: Progressive edema signals impaired venous return or rising intracompartmental pressure. It reflects worsening limb status under the cast. This change, with slowed refill, supports risk for compartment syndrome.

• Malunion: Malunion develops over weeks due to misalignment during healing. No imaging or prolonged healing time is reported. Acute symptoms like swelling and pain don’t indicate this long-term issue.

• Physeal damage: Growth plate injury would affect long-term limb development. The adolescent shows intact toe movement and normal limb function otherwise. No evidence of joint or bone disruption is presented.

• Inability to ambulate: The femur fracture and cast already restrict ambulation. Lack of walking is expected at this stage. It doesn't suggest any specific complication like infection or compartment syndrome.

• Infection: Fever is low-grade and expected post-injury or from opioids. No redness, drainage, or systemic illness is present. Pain is stable and localized, not escalating or spreading.

• Decreased dorsalis pedis pulse: Pulses are 2+, meaning circulation is present and adequate. Decreased or absent pulse would indicate severe compromise, but that is not seen here. It does not reflect early compartment syndrome.

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A nurse is reinforcing discharge instructions with a client who speaks a different language than the nurse. Which of the following actions should the nurse document in the client's medical record to ensure the language needs are met?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is participating in an interprofessional team meeting for a client. Which of the following information about the client should the nurse Include?

Correct Answer is B

Explanation

A nurse is assisting with the care of an adolescent. Exhibits Complete the following sentence by using the lists of options. The adolescent is at risk for developing as dropdown evidenced by dropdown

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"D"}

Explanation

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