A nurse is caring for a client who has acute appendicitis and speaks a different language than the nurse. The client is scheduled to undergo an appendectomy. Which of the following actions should the nurse take? (Select all that apply.)

Show the client pictures that illustrate the surgery.

Provide the client with written information in the client's primary language

Provide the client with a professional interpreter to explain the surgery

Ask a member of the client's family to discuss the surgery with the client.

Ask the client if they understand the risks of the surgery

Answer and Explanation

Correct Answer : A,B,C

A. Show the client pictures that illustrate the surgery: Visual aids can help bridge language barriers by providing a clear understanding of complex procedures. Pictures can reinforce verbal explanations and improve the client's ability to comprehend the surgical process, especially when language proficiency is limited.

B. Provide the client with written information in the client's primary language: Providing written materials in the client's native language ensures that the client has access to accurate, understandable information. This supports informed consent and allows the client to review the details at their own pace, enhancing comprehension.

C. Provide the client with a professional interpreter to explain the surgery: Using a professional medical interpreter is crucial for accurately conveying medical information. It ensures the client fully understands the procedure, risks, and benefits, which is necessary for informed consent and legal protection of client rights.

D. Ask a member of the client's family to discuss the surgery with the client: Family members should not be used as interpreters because they may lack medical knowledge and can introduce bias or inaccuracies. Relying on family could compromise the client's understanding and confidentiality.

E. Ask the client if they understand the risks of the surgery: Simply asking if the client understands without first ensuring effective communication through appropriate language services does not guarantee true understanding. The nurse must first use proper communication tools, like an interpreter or translated materials.

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Correct Answer is A

Explanation

A. "I will support your decision and help you explain it to others.": This response respects the client's autonomy and decision-making rights. It also offers emotional support and assistance in communicating the client's wishes to other healthcare team members or family, promoting dignity and advocacy.

B. "Let me explain the pros and cons of your decision.": This response may sound judgmental and suggest that the nurse is trying to influence the client's decision. Once a competent client has made a choice, the nurse’s role is to support it rather than attempt to persuade or second-guess it.

C. "I suggest you discuss this decision with your family first.": While family discussions can be valuable, the client has the primary right to make healthcare decisions. Suggesting they must discuss it with family could delay honoring the client’s wishes or create unnecessary emotional pressure.

D. "I will send the social worker in to discuss this decision with you.": While a social worker can provide additional support, immediately deferring to someone else instead of acknowledging the client’s decision can make the client feel dismissed. The nurse should first validate and support the client’s expressed wishes.

A. a 3-month history of unplanned weight loss, increased sweating and heat intolerance, and feeling fatigued and unable to sleep well B. Reports last menstrual period was 3 months ago C. Exophthalmus noted, goiter visualized on neck. Client’s partner reports that the client is imitable and anxious lately D. Abdomen soft, fat, normoactive bowel sounds in all four quad states E. No abnormal heart sounds heard

Correct Answer is ["A","B","C"]

Explanation

3-month history of unplanned weight loss, increased sweating, heat intolerance, fatigue, and difficulty sleeping: These symptoms are classic for hyperthyroidism and suggest worsening metabolic imbalance. They require follow-up because untreated hyperthyroidism can lead to serious complications like thyroid storm.
Reports last menstrual period was 3 months ago: Amenorrhea or menstrual irregularities are common in hyperthyroidism due to hormonal disruption. This finding supports the diagnosis and needs follow-up for endocrine and reproductive health management.
Exophthalmos noted: Exophthalmos, or bulging eyes, is associated with Graves' disease and indicates autoimmune involvement affecting the orbital tissues. It can lead to complications like corneal ulceration or vision loss if severe and thus requires ophthalmologic evaluation.
Goiter visualized on neck: A visible goiter reflects thyroid gland enlargement, often due to hyperstimulation from excess thyroid hormones. It requires ongoing monitoring to assess for airway compromise, dysphagia, or further gland enlargement.
Client’s partner reports irritability and anxiety: Behavioral and mood changes like irritability and anxiety are manifestations of hyperthyroidism affecting neurological function. Persistent symptoms can impair quality of life and must be addressed as part of comprehensive treatment planning.

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A nurse is caring for a client who has acute appendicitis and speaks a different language than the nurse. The client is scheduled to undergo an appendectomy. Which of the following actions should the nurse take? (Select all that apply.)

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