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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Free Nursing Study Resources

Correct Answer is C

Explanation

A. Multiple yellow lesions with a grainy surface. These could indicate xanthomas, which are associated with lipid disorders and may warrant further investigation and treatment.

B. Large, flat, dark red irregular area on the neck. This could be a port-wine stain, which is typically a congenital condition and may not require immediate medical intervention unless associated with other symptoms.

C. Bluish discoloration of the nail beds. This indicates cyanosis, which can be a sign of hypoxia or cardiovascular issues. It requires prompt evaluation by a healthcare provider to determine the underlying cause and necessary interventions.

D. Multiple silver striae on the abdomen. Striae, or stretch marks, are usually benign and often result from rapid weight changes or hormonal variations. They typically do not require immediate medical attention.

A. Teach the client to rotate the meal plate to visualize all the food on the plate. B. Instruct the client to lift the left extremities with the right hand when transferring. C. Implement precautions when the client is judging distances during transfers. D. Encourage the client to touch, wash, look at, and dress the affected side first.

Correct Answer is C

Explanation

A. Teach the client to rotate the meal plate to visualize all the food on the plate: While this intervention may be helpful for other reasons, it does not directly address the client’s difficulty walking in a straight line.

B. Instruct the client to lift the left extremities with the right hand when transferring: This intervention helps with weight-bearing and balance during transfers. It compensates for the left hemiplegia and promotes stability.

C. Implement precautions when the client is judging distances during transfers: This is crucial. Clients with hemiplegia may have impaired spatial awareness and difficulty judging distances. Strategies like using a gait belt, providing cues, or ensuring a clear path can help prevent falls. Implementing precautions during transfers helps prevent falls.

D. Encourage the client to touch, wash, look at, and dress the affected side first: While this approach promotes independence, it does not directly address the client’s gait instability.

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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

When assessing a client's skin, which finding should the nurse report to the healthcare provider?

Correct Answer is C

Explanation

While assisting a client to ambulate who has left hemiplegia due to a stroke, the nurse notices that the client is having difficulty walking in a straight line. Based on this assessment finding, it is most important to include which intervention in this client's plan of care?

Correct Answer is C

Explanation

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