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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. "Go to bed at least 2 hours earlier than usual.": Going to bed earlier may increase total sleep time, but it does not directly address the cause of nighttime awakening—frequent urination. Earlier bedtime alone is unlikely to improve the client’s quality of sleep.
B. "Have a snack before bedtime.": A bedtime snack may help prevent nausea or maintain blood sugar levels but does not reduce nighttime urinary frequency. In some cases, it might lead to increased fluid intake, potentially worsening nocturia.
C. "Drink a cup of chamomile tea at bedtime.": While chamomile may promote relaxation, it is also a fluid, which can increase bladder activity during the night. Encouraging tea before bed may worsen the client's urinary frequency and sleep disruption.
D. "Take regular rest periods during the day.": Taking rest periods throughout the day can help reduce overall fatigue and minimize sleep disruption caused by nocturia. Resting during the day compensates for nighttime interruptions and supports maternal well-being in early pregnancy.
Correct Answer is D
Explanation
Rationale:
A. Shortness of breath when climbing stairs: Mild dyspnea is common in the third trimester due to the upward displacement of the diaphragm by the enlarging uterus. This is typically not a concerning sign unless it occurs at rest or is accompanied by other symptoms like chest pain.
B. Periodic numbness of the fingers: Numbness or tingling in the hands and fingers during pregnancy can be caused by carpal tunnel syndrome due to fluid retention. While uncomfortable, it is a benign and relatively common symptom that usually resolves postpartum.
C. Leukorrhea: Leukorrhea, or increased vaginal discharge, is a normal finding in late pregnancy. It helps prevent ascending infections and is only concerning if it becomes foul-smelling, itchy, or changes in color, which could indicate infection.
D. Blurred vision: Blurred vision during the third trimester can be a sign of pregnancy-induced hypertension or preeclampsia. It may indicate cerebral involvement or elevated blood pressure and requires immediate evaluation by the healthcare provider.
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