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

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

Give the interpreter a form that lists the interview questions.

Use an interpreter throughout client's hospitalization.

Maintain eye contact with the client when questions are asked.

Answer and Explanation

The Correct Answer is D

Rationale:
A. Ask the interpreter to tell the client to write down questions: Asking the client to write down questions places an unnecessary burden on communication and may not be feasible if the client struggles with written English or literacy. It does not foster an open and supportive dialogue during the interview.

B. Give the interpreter a form that lists the interview questions: Providing the interpreter with a form could help with preparation but does not substitute for real-time interpretation and direct engagement. It risks turning the encounter into a transactional experience rather than building therapeutic rapport with the client.

C. Use an interpreter throughout client's hospitalization: While it is important to use an interpreter when needed, the question asks about what the nurse should implement during the interview itself. Additionally, not all interactions may require an interpreter if communication becomes clearer over time, so blanket use is not always appropriate.

D. Maintain eye contact with the client when questions are asked: Maintaining eye contact reinforces that the nurse is communicating directly with the client, not the interpreter. It promotes trust, respect, and engagement, helping the client feel heard and respected even when a language barrier exists.

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Correct Answer is B

Explanation

Rationale:
A. Assist the client to stand at the bedside long enough to observe posture: Assisting the client to stand would violate the bedrest order, which is in place to prevent complications such as increased intracranial pressure or falls following a CVA. Standing could pose unnecessary risks and is not appropriate when safer alternatives are available.

B. Observe the client's ability to sit upright or unassisted while in the bed: Evaluating posture can still be done safely within the constraints of bedrest by assessing how well the client can maintain an upright seated position. This allows the nurse to assess muscle tone, balance, and neurological function without compromising safety.

C. Document that posture could not be evaluated due to prescribed bedrest: Bedrest limits standing or walking, but it does not prevent all forms of posture evaluation. The nurse still has a responsibility to assess posture in ways that align with safety protocols and should not omit this part of the neurological assessment.

D. Ask the client to describe normal posture while walking and standing: Relying on the client's verbal report does not replace direct observation. Objective assessment is necessary for accurate neurological evaluation, especially in post-CVA clients where deficits in muscle control and balance may not be fully recognized by the client.

A. Flex and hold as opposing force is applied. B. Perform sets of passive range of motion. C. Hold arms straight forward with eyes closed. D. Stand on each foot without assistance.

Correct Answer is A

Explanation

Rationale:
A. Flex and hold as opposing force is applied: This technique evaluates the strength of prime-mover muscle groups by having the client actively flex against resistance. It allows the nurse to assess muscle function, endurance, and the ability to maintain strength against an external force.

B. Perform sets of passive range of motion: Passive range of motion exercises assess joint flexibility and mobility but do not evaluate the client's active muscle strength since the movements are performed by the examiner rather than the client.

C. Hold arms straight forward with eyes closed: This action is part of a neurological assessment, specifically testing for proprioception and balance (Romberg test), not a direct evaluation of muscle group strength.

D. Stand on each foot without assistance: Standing on one foot assesses balance and coordination more than muscle strength. It involves neuromuscular control but does not directly isolate or test specific prime-mover muscle groups under resistance.

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The nurse is performing a health interview for 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

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Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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