The nurse is assessing a client in the clinic who is frightened and does not understand English. Which intervention should the nurse implement first?

Request a family member to remain with the client.

Ask for the support of one of the client’s friends.

Use drawings that are universal for all cultures.

Obtain a staff member who is a bilingual interpreter.

Answer and Explanation

The Correct Answer is D

Choice A: Request a family member to remain with the client is not the best intervention because it may compromise the confidentiality and accuracy of the assessment. The family member may not be able to translate correctly or may influence the client’s responses.
Choice B: Ask for the support of one of the client’s friends is not the best intervention because it may also violate the privacy and validity of the assessment. The friend may not be qualified or willing to translate or may have a conflict of interest with the client.
Choice C: Use drawings that are universal for all cultures is not the best intervention because it may not be sufficient or appropriate for the assessment. Drawings may not convey all the information needed or may be misinterpreted by the client.
Choice D: Obtain a staff member who is a bilingual interpreter is the best intervention because it facilitates the communication and understanding between the nurse and the client. The interpreter should be trained and certified in medical terminology and cultural sensitivity.

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Correct Answer is A

Explanation

Choice A reason: This is the correct action to take when the nurse hears loud Korotkoff sounds immediately after releasing the air valve. This indicates that the cuff was not inflated high enough to occlude the arterial blood flow and the initial systolic reading was inaccurate. The nurse should release the air, wait for 15 to 30 seconds, and then reinflate the cuff to 30 mm Hg above the first systolic sound. This will ensure a more accurate measurement of the blood pressure.

Choice B reason: This is not the correct action to take when the nurse hears loud Korotkoff sounds immediately after releasing the air valve. Continuing the blood pressure assessment until the last Korotkoff sound is heard will result in a lower systolic reading and a higher diastolic reading than the actual blood pressure of the client. The nurse should release the air and reinflate the cuff to 30 mm Hg above the first systolic sound.

Choice C reason: This is not the correct action to take when the nurse hears loud Korotkoff sounds immediately after releasing the air valve. Repositioning the stethoscope in the antecubital fossa over the palpable brachial pulse point will not change the fact that the cuff was not inflated high enough to occlude the arterial blood flow. The nurse should release the air and reinflate the cuff to 30 mm Hg above the first systolic sound.

Choice D reason: This is not the correct action to take when the nurse hears loud Korotkoff sounds immediately after releasing the air valve. Inflating the cuff quickly to a higher mm Hg reading than the previously auscultated systolic sound will cause discomfort and pain to the client and may damage the blood vessels. The nurse should release the air and reinflate the cuff to 30 mm Hg above the first systolic sound.

A. Begin with questions that are less sensitive in nature. B. Ask questions in a vague, non-specific format. C. Get the most difficult questions over with first. D. Share personal values to put the client at ease.

Correct Answer is A

Explanation

Choice A Reason: This is correct because beginning with questions that are less sensitive in nature can help establish rapport and trust with the client, and make the client more comfortable and willing to disclose personal information.

Choice B Reason: This is incorrect because asking questions in a vague, non-specific format can confuse the client and lead to inaccurate or incomplete data. The nurse should ask clear, direct, and open-ended questions that elicit relevant information.

Choice C Reason: This is incorrect because getting the most difficult questions over with first can make the client feel anxious, embarrassed, or defensive, and discourage further communication. The nurse should build up to the more sensitive questions gradually and respectfully.

Choice D Reason: This is incorrect because sharing personal values to put the client at ease can be inappropriate and unprofessional, as it may impose the nurse's beliefs or opinions on the client or create bias or judgment. The nurse should maintain a neutral and objective attitude and respect the client's values.

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The nurse is assessing a client in the clinic who is frightened and does not understand English. Which intervention should the nurse implement first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Explanation

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