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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason: This is incorrect because contacting the healthcare provider about the frequency of pain medication is a dependent intervention that requires an order from the provider. The nurse should first use independent interventions such as reviewing available prescriptions or providing non-pharmacological measures.
Choice B Reason: This is incorrect because encouraging the client to allow more time for the medication to work can imply that the nurse does not believe or validate the client's report of pain. It also can delay effective pain relief and increase suffering.
Choice C Reason: This is correct because reviewing the medical record for additional pain medication prescriptions can help identify alternative or adjunctive options for pain management, such as breakthrough doses, rescue doses, or non-opioid analgesics.
Choice D Reason: This is incorrect because administering an additional dose of morphine sulfate 0.2 mg intravenously can cause overdose, respiratory depression, or addiction. The nurse should follow the prescribed dosage, route, and interval of administration and monitor for adverse effects.
Correct Answer is D
Explanation
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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