The nurse is performing a health assessment interview with a client who does not speak fluent English and has obtained an interpreter. Which action should the nurse implement?

Use an interpreter throughout the client's hospitalization.

Maintain eye contact with clients when questions are asked.

Ask the interpreter to tell the client to write down questions.

Give the interpreter a form that lists the interview questions.

Answer and Explanation

The Correct Answer is B

A. Use an interpreter throughout the client's hospitalization. Consistently using an interpreter throughout the client's hospitalization ensures clear communication, improves understanding, and enhances the quality of care. However, this answer does not address the specific context of the health assessment interview.

B. Maintain eye contact with client when questions are asked. Maintaining eye contact with the client rather than the interpreter helps build rapport and shows respect and engagement with the client. This practice encourages the client to feel directly involved in the conversation, even though an interpreter is present, fostering a sense of trust and comfort.

C. Ask the interpreter to tell the client to write down questions. This option may be less effective if the client has limited literacy or is uncomfortable with writing. Additionally, it adds an unnecessary step that can complicate the communication process.

D. Give the interpreter a form that lists the interview questions. Providing the interpreter with a list of questions might help streamline the process but can depersonalize the interaction and reduce the engagement with the client. It is more effective for the nurse to ask questions directly and maintain communication with the client.

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Correct Answer is B

Explanation

A. Determine the client's most recent hemoglobin level: While low hemoglobin can be associated with conditions that cause clubbing, it's not the initial step. Documenting the finding is more important first.

B. Document the presence of nail bed clubbing: An angle of 200 degrees between the nail and nail bed is a classic sign of clubbing, which can be associated with various underlying conditions.

C. Administer a PRN prescription for oxygen: This is not indicated unless the client has respiratory problems, and clubbing itself doesn't necessitate oxygen.

D. Consult with a podiatrist: Consulting a podiatrist might be necessary for nail care in some situations, but it's not the most urgent action for nail bed clubbing. Documenting the finding and investigating the underlying cause is the priority.

A. Conduct an assessment of functional capacity and environmental hazards. B. Distinguish between symptoms caused by disease and those due to aging. C. Obtain a medication history including prescription and non-prescription drugs. D. Emphasize the need to place advance directives in the medical record.

Correct Answer is C

Explanation

A. Functional capacity: While important for older adults, it's not the most pressing concern during this routine follow-up exam.

B. Distinguishing symptoms: This is an ongoing process, but not the most critical element for this visit.

C. Obtain a medication history including prescription and non-prescription drugs. Cataract surgery often involves medication changes or new medications to prevent infection or manage other post-operative needs. An updated medication history helps identify potential interactions or side effects.

D. Advance directives: While important for all adults, it might not be the most urgent topic for this specific follow-up exam focused on managing existing conditions and potential post-surgical medications.

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The nurse is performing a health assessment interview with a client who does not speak fluent English and has obtained an interpreter. Which action should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

In assessing a client's nailbeds, the nurse notes that the angle between the nail and the nailbed is 200 degrees. Which action should the nurse take?

Correct Answer is B

Explanation

Correct Answer is C

Explanation

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