A nurse is using a medical interpreter to explain a procedure to a client who speaks a different language than the nurse. Which of the following actions should the nurse take?
Use metaphors to help express meaning.
Ask the client's family members to assist the interpreter.
Direct all information to the client.
Include medical terminology when explaining the procedure.
The Correct Answer is C
A. Use metaphors to help express meaning: Using metaphors can introduce confusion when working through an interpreter, as cultural and linguistic differences may cause misinterpretation. Medical explanations should be clear, simple, and literal to ensure the client accurately understands the information.
B. Ask the client's family members to assist the interpreter: Family members should not serve as interpreters for medical explanations. Using untrained interpreters can lead to errors, breaches of confidentiality, and incomplete or inaccurate information. Professional medical interpreters ensure accurate communication and patient safety.
C. Direct all information to the client: When using a medical interpreter, the nurse should address all information directly to the client, not the interpreter. This approach maintains respect for the client, promotes engagement, and ensures that the client is the focus of the teaching, while the interpreter facilitates communication.
D. Include medical terminology when explaining the procedure: Excessive medical terminology can confuse clients, especially when translation is involved. The nurse should use plain language, explain terms in simple words, and avoid jargon to ensure comprehension through the interpreter.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
. Instruct the client to tilt their head forward when swallowing: Tilting the head slightly forward, or the “chin-tuck” technique, helps protect the airway during swallowing by narrowing the airway entrance and facilitating safe passage of food and liquids into the esophagus. This method reduces the risk of aspiration, which is a primary concern in clients with dysphagia.
B. Position the client at a 45° angle during mealtime: A 45° angle is insufficient to protect the airway. Clients with dysphagia should be positioned upright at 90° during meals to promote gravity-assisted swallowing and reduce the risk of aspiration pneumonia.
C. Allow 15 minutes for the client's mealtimes: Clients with dysphagia often require more time to safely chew and swallow, and limiting mealtime to only 15 minutes may increase the risk of choking or aspiration. Extended, unrushed feeding is recommended.
D. Encourage the client to use liquids to clear food from the mouth: Thin liquids can increase the risk of aspiration in clients with dysphagia. Instead, small sips of appropriately thickened liquids are safer for clearing the oral cavity and aiding safe swallowing.
Correct Answer is ["B","C","D","E","F"]
Explanation
A. Oxygen saturation: The client’s oxygen saturation is 98% on room air, which is within normal limits (95–100%) and does not require immediate further evaluation in the context of the other findings.
B. Weight: The client has experienced a 2.26 kg (5 lb) weight loss in one week, which is significant and may indicate malnutrition, chronic infection, or systemic disease such as tuberculosis. Rapid, unintentional weight loss warrants further evaluation.
C. Temperature: The client has a low-grade fever of 38.1° C (100.5° F), which is abnormal and suggests an ongoing infection or inflammatory process. Persistent fever, especially in combination with night sweats, is concerning for conditions such as tuberculosis.
D. Report of cough: A productive cough lasting 4 days, especially when paired with other systemic symptoms, requires further diagnostic evaluation (such as a chest X-ray) to rule out pneumonia or tuberculosis.
E. Travel history: Recent travel to South Africa, where tuberculosis prevalence is higher, increases the risk for exposure to Mycobacterium tuberculosis. This epidemiological factor warrants further investigation for infectious causes of the client’s symptoms.
F. Sputum characteristics: Blood-tinged sputum (hemoptysis) is an abnormal finding. Hemoptysis can indicate serious conditions such as tuberculosis, pneumonia with necrosis, or pulmonary embolism, necessitating further diagnostic evaluation.
G. Heart rate: The client’s heart rate of 98/min is mildly elevated but can be explained by fever or mild dehydration. It does not independently indicate an urgent need for further evaluation.
H. Blood pressure: Blood pressure of 112/88 mm Hg is within acceptable limits for an adult and does not indicate an immediate concern in this context.
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