A nurse is developing the plan of care for a client who does not speak the same language as the nurse. Which of the following interventions should the nurse include?

Determine the client's level of fluency in his primary language.

Encourage the client to nod to indicate understanding.

Speak directly to the interpreter when teaching the client.

Make sure a family member is present to interpret for the staff.

Answer and Explanation

The Correct Answer is A

This is important because it allows the nurse to assess the client's ability to communicate in their primary language. Knowing the client's level of fluency helps the nurse determine the most effective communication strategies and whether an interpreter is necessary.

B. While nodding can be a form of nonverbal communication indicating understanding, relying solely on this may not accurately gauge the client's comprehension.

C. Even in the presence of n interpreter, the nurse should speak directly to the client.

D. Family members may not be proficient in both languages or may not accurately convey medical information.

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Correct Answer is ["B","D"]

Explanation

B. Assessing the client's reliability as a historian involves gathering information about their medical history, symptoms, and health behaviors. While this is an important aspect of client assessment, it may not be immediately necessary right before performing the physical exam.

D. Constructing the client's family genogram is an important aspect of assessing their family history, which may be relevant to their current health condition. However, this task is not immediately necessary right before performing the physical exam and can be completed at a later time during the assessment process.

A. The client explains they are not planning to leave their home. B. The client thinks their home will be safer now that there is a baby in the house C. The client thanks the nurse for the information. D. The client puts the number of the crisis center into their phone.

Correct Answer is D

Explanation

It indicates that the client acknowledges the importance of having a safety plan and is willing to take proactive measures to ensure their well-being and that of their child. This response suggests a positive engagement with the safety plan provided by the nurse.
A. This response indicates that the client may not perceive their current situation as unsafe or may not be ready to take action to address potential safety concerns.
B. This response suggests that the client may have misconceptions about how the presence of a baby in the home affects safety, especially in the context of intimate partner violence.
C. While expressing gratitude for the information provided is a positive response, it does not necessarily indicate whether the client understands the seriousness of the situation or plans to utilize the resources provided.

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A nurse is developing the plan of care for a client who does not speak the same language as the nurse. Which of the following interventions should the nurse include?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A student nurse is preparing a client room for the treatment of an ovarian cyst. What would be least important for the student nurse to do immediately before performing the client's physical exam with the primary nurse? (Select All that Apply.)

Correct Answer is ["B","D"]

Explanation

Correct Answer is D

Explanation

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