A nurse is using the assistance of an interpreter to reinforce discharge teaching to a client who does not speak the same language as the nurse. Which of the following actions should the nurse plan to take when working with an interpreter?

Use humor to decrease tension.

Speak in short sentences.

Speak in third person.

Talk directly to the interpreter.

Answer and Explanation

The Correct Answer is B

A. Use humor to decrease tension: Humor may not translate well across cultures and languages, and it can lead to miscommunication or offend the client unintentionally. It is better to maintain a respectful, clear, and professional communication style when using an interpreter.

B. Speak in short sentences: Using short, clear sentences helps the interpreter accurately convey the nurse’s message to the client. It allows for better understanding and avoids overwhelming the interpreter with complex information that could get misinterpreted.

C. Speak in third person: Speaking in third person can cause confusion and distance the nurse from the client. It is best to speak directly to the client using first and second person ("I" and "you") so the interaction feels more personal and respectful.

D. Talk directly to the interpreter: The nurse should always speak directly to the client, maintaining eye contact and body language with the client. The interpreter is there to facilitate communication, not to replace the direct interaction between the nurse and the client.

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Correct Answer is ["B","D","E","G","H"]

Explanation

Temperature: A temperature of 37.5° C (99.5° F) is within the normal to slightly elevated range and is not high enough to be classified as fever. Therefore, it does not require immediate reporting unless accompanied by other signs of infection or systemic illness.
Sclera: Yellow-tinged sclera suggests jaundice, indicating possible liver dysfunction, which could be related to substance use or hepatitis. Jaundice is a significant clinical finding that requires immediate provider notification for further evaluation and management.
Bowel sounds: Hyperactive bowel sounds are a non-specific finding and can result from gastrointestinal irritation, substance use, or stress. Alone, they do not warrant urgent reporting unless accompanied by more serious signs like severe pain or vomiting.
Abdominal tenderness: Epigastric tenderness could suggest gastrointestinal complications such as hepatitis, pancreatitis, or gastritis, especially in the context of drug use. Abdominal pain on palpation is a concerning symptom that must be reported for further diagnostic workup.
Anorexia: Significant anorexia along with nausea, vomiting, and substance use points to potential systemic illness or gastrointestinal involvement. In adolescents, persistent anorexia is a warning sign that needs prompt evaluation to prevent nutritional deficiencies and worsening health.
Breath sounds: Clear breath sounds are a normal finding and do not require immediate provider notification. There are no respiratory concerns indicated by the lung assessment provided in the notes.
Heart rate: A heart rate of 103/min indicates mild tachycardia, which could be due to dehydration, substance use, or an underlying systemic condition. Tachycardia should be reported to assess if immediate interventions like fluid replacement are necessary.
Skin: Dry skin with poor turgor signals dehydration, a critical finding especially with the reported vomiting and drug use. Dehydration can rapidly worsen and must be addressed by the provider for fluid management and further care.

A. Open nearby doors and windows when the fire alarm sounds B. Attempt to extinguish the fire before evacuating clients. C. Have ambulatory clients walk independently to a safe location D. Aim the spray of the fire extinguisher at the top of the fire.

Correct Answer is C

Explanation

A. Open nearby doors and windows when the fire alarm sounds: Opening doors and windows during a fire can cause the fire to spread more rapidly by feeding it with additional oxygen. Doors should be closed to contain the fire and reduce the spread of smoke.

B. Attempt to extinguish the fire before evacuating clients: Client safety is the priority in a fire situation. Evacuation should occur first, and attempts to extinguish the fire should only be made if it is safe to do so without putting clients or staff at risk.

C. Have ambulatory clients walk independently to a safe location: Ambulatory clients should be instructed to evacuate independently if they can do so safely, freeing staff to assist clients who are immobile or require more help during the evacuation.

D. Aim the spray of the fire extinguisher at the top of the fire: The proper technique is to aim at the base of the fire, not the top, to effectively extinguish the flames by removing the fire's source of fuel.

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A nurse is using the assistance of an interpreter to reinforce discharge teaching to a client who does not speak the same language as the nurse. Which of the following actions should the nurse plan to take when working with an interpreter?

Nursing Test Bank

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