A nurse is reinforcing discharge instructions with a client who speaks a different language than the nurse. Which of the following actions should the nurse document in the client's medical record to ensure the language needs are met?
Nurse addressing the client directly while the interpreter is present.
Nurse asking the client for questions at the end of the instructions.
Staff member serving as an interpreter for the client.
Family member acting as an interpreter for the client.
The Correct Answer is A
Rationale:
A. Nurse addressing the client directly while the interpreter is present: This demonstrates culturally competent and client-centered care. Documenting that the nurse communicated directly with the client through a qualified interpreter shows appropriate use of interpretation services and respect for the client's autonomy.
B. Nurse asking the client for questions at the end of the instructions: While this is good practice, it does not specifically demonstrate that the client's language needs were addressed. Without interpreter documentation there’s no assurance the client understood the information.
C. Staff member serving as an interpreter for the client: Unless the staff member is a certified medical interpreter, using them for interpretation may result in miscommunication and is not best practice. Documentation should reflect use of trained professionals.
D. Family member acting as an interpreter for the client: Family members should not be used for interpretation due to risks of bias, inaccuracies, and privacy violations. Professional interpreters are necessary to ensure accurate, safe, and confidential communication.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. Anger: Anger is typically characterized by blaming others, expressing frustration, or resentment toward the situation, self, or those perceived to be responsible. It often follows denial and precedes bargaining in the stages of grief.
B. Bargaining: The statement "If only I had another day with them" reflects bargaining, a grief stage where individuals dwell on what could have been done differently to prevent the loss. This often includes hypothetical thinking or “what if” scenarios as a way to cope with the pain.
C. Denial: Denial involves refusing to accept the reality of the loss. It may manifest as disbelief or numbness, rather than expressing a desire to have more time or change past events, as seen in this client’s statement.
D. Depression: Depression in grief involves deep sadness, withdrawal, or feelings of hopelessness. While the client may be experiencing sorrow, the focus on "if only" thinking indicates bargaining more than the full emotional weight of depression.
Correct Answer is A
Explanation
Rationale:
A. Ensure the client swallows each dose of medication: Clients with recent suicide attempts are at risk for hoarding medications to use in a future overdose. The nurse should closely monitor medication administration and confirm that each dose is swallowed to ensure safety.
B. Limit the personal toiletries in the client's room to cologne: Cologne often contains alcohol and could be misused for ingestion or fire-related self-harm. It should not be permitted. All personal items should be carefully screened to eliminate potential hazards.
C. Observe the client's behavior every 2 hr: Monitoring every 2 hours is insufficient for a client at high risk of suicide. More frequent or continuous observation (such as 1:1 supervision) is typically warranted during the acute phase to ensure immediate safety.
D. Keep the client's door shut when they are in the room: Keeping the door closed limits visibility and increases the risk of the client engaging in self-harm without detection. The door should remain open or observation should be maintained to ensure the client’s ongoing safety.
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