A nurse is caring for a client who speaks a different language and is having difficulty understanding them. Which of the following actions should the nurse take?
Direct all communication through the client's family.
Limit instructions to simple and short one-sentence instructions.
Ask a coworker who speaks the client's language to translate information.
Find an available interpreter to help with communication.
The Correct Answer is D
A. "Direct all communication through the client's family." While family members may assist in communication, they may omit, alter, or misunderstand medical information. Using a trained medical interpreter ensures accurate and confidential communication.
B. "Limit instructions to simple and short one-sentence instructions." While clear, simple instructions are helpful, language barriers still exist. This does not fully address the client’s difficulty in understanding.
C. "Ask a coworker who speaks the client's language to translate information." A coworker may not be a certified medical interpreter and could misinterpret critical information. Medical translation should always be done by a qualified interpreter.
D. "Find an available interpreter to help with communication." A trained medical interpreter provides accurate, unbiased, and professional translation, ensuring that the client fully understands their care and can make informed decisions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "The client's room number and diagnosis are written on the hallway communication board." This is a breach of client confidentiality because it publicly displays protected health information (PHI) where unauthorized individuals, including visitors and non-essential staff, could see it. This violates HIPAA (Health Insurance Portability and Accountability Act) regulations.
B. "The history and physical in the electronic medical record describes the client's previous suicide attempt." The electronic medical record (EMR) is a secure and appropriate place for documenting the client's health history. Access is restricted to healthcare providers involved in the client’s care.
C. "The time when the client can next have pain medication is written on their bedside communication board." This does not violate confidentiality, as it is relevant to the client’s direct care and is visible only to the healthcare team and the client.
D. "The client is wearing a color-coded bracelet that states they are a fall risk." Color-coded bracelets are a standard safety practice in hospitals to communicate important patient care needs to staff. This does not disclose specific medical information beyond the fall risk status.
Correct Answer is A
Explanation
A. High-pitched wheezing Wheezing indicates airway constriction, which is a sign of anaphylaxis, a life-threatening allergic reaction. This requires immediate intervention (e.g., stopping the medication, administering epinephrine, and providing oxygen).
B. Urticaria over the entire body While urticaria (hives) is a sign of an allergic reaction, it is not as urgent as airway compromise. It should still be reported but does not take immediate priority over wheezing.
C. Pruritis of the face Facial itching is a mild allergic reaction but does not indicate imminent airway compromise like wheezing does.
D. Rhinitis with clear discharge Nasal congestion or a runny nose can be a mild allergic reaction but is not an emergency.
Priority action: Apply the ABC (Airway, Breathing, Circulation) framework, which prioritizes airway compromise (wheezing) over skin-related allergic reactions.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.