Nokea
A young Spanish-speaking client is experiencing a spontaneous abortion (miscarriage). Which illustrates the best use of an interpreter to explain the situation to the client? Select all that apply.
- A. Ask the client to nod so the nurse can confirm the client understands the situation
- B. Attempt to use a female interpreter to avoid gender sensitivity
- C. Make good eye contact with the client (rather than the interpreter) when speaking
- D. Preferably use a personal friend or relative to facilitate client privacy under HIPAA
- E. Teach about one intervention at a time and in the order it will occur
Correct Answer: B,C,E
Rationale: A female interpreter respects cultural sensitivity, eye contact with the client fosters trust, and teaching one intervention at a time aids understanding. Friends/relatives as interpreters violate HIPAA.
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The nurse is reinforcing teaching about constipation prevention to a client. Which of the following client statements indicate appropriate understanding of the teaching? Select all that apply.
- A. Drinking more caffeinated drinks such as tea and soda helps to stimulate the bowel.
- B. Having a routine for bowel movements is important, but I should not wait if I feel the urge.
- C. I can use an over-the-counter laxative every other day if needed.
- D. I should try to eat more fruits and vegetables every day.
- E. Increasing my daily exercise level may help keep my bowel movements regular.
Correct Answer: B,D,E
Rationale: A routine, high-fiber diet, and exercise prevent constipation. Caffeine can dehydrate, and frequent laxative use is not recommended.
Two people call in sick on the medical-surgical unit and no additional help is available. The team consists of an RN, an LPN and an unlicensed assistive personnel (UAP). Which of these activities should the nurse assign to the UAP?
- A. Assist with plans for any clients discharged
- B. Provide basic hygiene care to all clients on the unit
- C. Assess a client after an acute myocardial infarction
- D. Gather the vital signs of all clients on the unit
Correct Answer: B
Rationale: Basic client care, which is routine, should be delegated to a UAP since the unit is short on help. The vital signs can be done by the RN and PN as they make rounds since this data is more critical to making decisions about the care of the clients.
The nurse is caring for a client who is in restraints due to violent behavior. The client states, 'I am a magician; I can get out of anything. There could be trouble now!' Which of the following actions would be most appropriate for the nurse to take?
- A. Notify other staff members that assistance is needed.
- B. Ask the client, 'Can you tell me why you think you are a magician?'
- C. Encourage discussion of the client's current feelings.
- D. Ask the client, 'What kind of trouble are you thinking about?'
Correct Answer: A
Rationale: The client's statement suggests a potential intent to escape restraints, posing a safety risk, so notifying staff for assistance is the priority.
The mother of a 1-week-old infant says to the nurse, 'When will that ugly black cord thing come off?' How should the nurse reply?
- A. Are you wiping it with alcohol each time you change the baby's diaper?'
- B. It usually comes off in 10 days to three weeks.'
- C. It sounds as if it bothers you. Would you like to talk about it?'
- D. It should be off by now. I'll have the doctor check to be sure there is no problem.'
Correct Answer: B
Rationale: The umbilical cord typically detaches in 10 days to 3 weeks, providing accurate information. Other responses are irrelevant or incorrect.
The clinic nurse reinforces teaching to a client with systemic lupus erythematosus. Which instructions will the nurse include? Select all that apply.
- A. Avoid annual influenza vaccination
- B. Avoid situations that cause physical and emotional stress
- C. Avoid sun exposure and ultraviolet light when possible
- D. Notify the health care provider if you have fever
- E. Use antibiotic soap to cleanse skin rashes
Correct Answer: B,C,D
Rationale: Stress, sun exposure, and infections can exacerbate lupus. Influenza vaccination is recommended, and antibiotic soap is unnecessary.