The nurse is performing a health assessment interview with a client who does not speak fluent English and has obtained an interpreter. Which action should the nurse implement?

Use an interpreter throughout the client's hospitalization.

Maintain eye contact with clients when questions are asked.

Ask the interpreter to tell the client to write down questions.

Give the interpreter a form that lists the interview questions.

Answer and Explanation

The Correct Answer is B

A. Use an interpreter throughout the client's hospitalization. Consistently using an interpreter throughout the client's hospitalization ensures clear communication, improves understanding, and enhances the quality of care. However, this answer does not address the specific context of the health assessment interview.

B. Maintain eye contact with client when questions are asked. Maintaining eye contact with the client rather than the interpreter helps build rapport and shows respect and engagement with the client. This practice encourages the client to feel directly involved in the conversation, even though an interpreter is present, fostering a sense of trust and comfort.

C. Ask the interpreter to tell the client to write down questions. This option may be less effective if the client has limited literacy or is uncomfortable with writing. Additionally, it adds an unnecessary step that can complicate the communication process.

D. Give the interpreter a form that lists the interview questions. Providing the interpreter with a list of questions might help streamline the process but can depersonalize the interaction and reduce the engagement with the client. It is more effective for the nurse to ask questions directly and maintain communication with the client.

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Correct Answer is C

Explanation

A. Contact social services for a temporary shelter. While contacting social services is important for the overall care of a homeless pregnant woman, it is not the immediate priority in the presence of placenta previa and vaginal bleeding.

B. Obtain a hemoglobin and hematocrit level. Assessing hemoglobin and hematocrit levels is important to evaluate the extent of blood loss and anemia, but the priority is to ensure the woman’s and fetus’s immediate safety due to placenta previa.

C. Have the client transported to the hospital. This is the correct action. Placenta previa can cause significant bleeding and requires immediate medical attention, including potential delivery. Transporting the client to the hospital ensures she receives the necessary urgent care.

D. Schedule weekly perinatal appointments. Weekly perinatal appointments are important for ongoing care, but in the context of active bleeding and placenta previa, immediate hospital care is necessary first.

A. Trapped subcutaneous air causing crepitus will be absorbed, so the finding is not significant. B. Since this client has only a small area of crepitus, it probably is not a significant finding. C. Crepitus is always abnormal and should be followed-up with a more detailed assessment. D. Since a fractured rib often creates crepitus, a chest x-ray should be scheduled immediately.

Correct Answer is C

Explanation

A. Trapped subcutaneous air causing crepitus will be absorbed, so the finding is not significant. While trapped air can be absorbed, crepitus can indicate underlying issues such as a pneumothorax or other trauma, so it should not be dismissed as insignificant.

B. Since this client has only a small area of crepitus, it probably is not a significant finding. The size of the area does not necessarily correlate with the severity of the underlying condition. Even a small area of crepitus should be investigated.

C. Crepitus is always abnormal and should be followed-up with a more detailed assessment. This is the most accurate interpretation. Crepitus indicates the presence of air in the subcutaneous tissues, which is always abnormal and warrants further investigation.

D. Since a fractured rib often creates crepitus, a chest x-ray should be scheduled immediately. While a chest x-ray can be part of the assessment, stating that a fractured rib "often" creates crepitus might be misleading. Crepitus can arise from other conditions, and a thorough assessment is needed before determining the exact cause.

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The nurse is performing a health assessment interview with a client who does not speak fluent English and has obtained an interpreter. Which action should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A pregnant, homeless woman who has received no prenatal care presents to the clinic in her third trimester because she is having vaginal bleeding, but reports that she is not in pain. Ultrasound reveals a placenta previa. Which action should the nurse implement?

Correct Answer is C

Explanation

During a routine physical examination of a client, chest palpation is determined to be normal except for a 2 inch (5.1 cm) diameter area of crepitus over the upper right anterior chest. Which interpretation is the most accurate for this finding?

Correct Answer is C

Explanation

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