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A nurse in a mobile health clinic is caring for a client who requires a tetanus immunization and is accompanied by his daughter. The client does not speak the same language as the nurse. Which of the following actions should the nurse take?
- A. Have the client's daughter communicate information about the procedure
- B. Arrange for a member of the client's community to interpret the teaching
- C. Identify the client's spoken dialect prior to contacting an interpreter
- D. Use professional terminology when providing education prior to the procedure
Correct Answer: C
Rationale: The correct answer is C: Identify the client's spoken dialect prior to contacting an interpreter. This is the most appropriate action because it ensures effective communication by matching the client with an interpreter who speaks the same dialect. This step shows cultural sensitivity and respects the client's language preference, promoting trust and understanding.
Other choices are incorrect:
A: Having the client's daughter communicate may not guarantee accurate information exchange due to potential language barriers.
B: Arranging for a community member to interpret may not ensure confidentiality or accuracy in communication.
D: Using professional terminology without ensuring understanding may lead to confusion and hinder effective communication.
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A nurse is caring for a client who is homeless. Which of the following actions should the nurse take first?
- A. Determine the client's understanding of her living situation
- B. Assist the client to develop goals for obtaining shelter
- C. Discuss the risks of being homeless with the client
- D. Develop client teaching using a variety of strategies
Correct Answer: A
Rationale: The correct answer is A: Determine the client's understanding of her living situation. This is the first step because it allows the nurse to assess the client's current situation and needs. Understanding the client's perspective is crucial for providing effective care and support. Assisting the client in developing goals (B) or discussing risks (C) should come after understanding the client's current situation. Developing client teaching (D) is important but should be based on the client's understanding and needs, which is why it comes after assessing their understanding.
A nurse is caring for a client who is unconscious. Which of the following actions should the nurse take when providing oral care for the client?
- A. Test for the presence of the client's gag reflex
- B. Place the client in the supine position
- C. Use a firm toothbrush for tooth and gum care
- D. Use 2 gauze-wrapped fingers to hold the mouth open
Correct Answer: A
Rationale: The correct answer is A: Test for the presence of the client's gag reflex. This is important to prevent aspiration during oral care. By testing the gag reflex, the nurse can ensure the client's airway is protected. Placing the client in the supine position (choice B) can increase the risk of aspiration. Using a firm toothbrush (choice C) can damage the delicate tissues in the mouth. Using 2 gauze-wrapped fingers to hold the mouth open (choice D) can increase the risk of injury to the client's oral mucosa.
A nurse is providing education to a group of adolescents who are pregnant and attending high school. Which of the following information should the nurse include in their teaching?
- A. The need for supplemental folic acid is greatest during the third trimester
- B. The incidence of high birth weight infants is higher in adolescent pregnancy
- C. Pregnant adolescents need to gain less weight than adult mothers
- D. Caffeinated beverages should be replaced with caffeine-free beverages
Correct Answer: D
Rationale: The correct answer is D: Caffeinated beverages should be replaced with caffeine-free beverages. Pregnant adolescents should limit their caffeine intake as excessive caffeine can lead to complications during pregnancy. Caffeine can cross the placenta and affect the baby's heart rate and sleep patterns. It is important for pregnant adolescents to switch to caffeine-free beverages to ensure the health and well-being of both the mother and baby.
A: The need for supplemental folic acid is not specific to the third trimester, it is important throughout pregnancy.
B: The incidence of high birth weight infants is not necessarily higher in adolescent pregnancy compared to adult mothers.
C: Pregnant adolescents actually need to gain weight within the recommended range, similar to adult mothers, to support fetal growth and development.
A client who has diabetes mellitus asks a home health nurse to help her adapt some of her traditional cultural foods to fit her meal plan. Which of the following is the first action the nurse should take when assisting this client?
- A. Provide the client with a printed recipe
- B. Observe the client during preparation of traditional foods
- C. Use cookbooks to include traditional foods in meal plans
- D. Explain the diabetes exchange list
Correct Answer: B
Rationale: The correct answer is B. Observing the client during the preparation of traditional foods allows the nurse to understand the client's current cooking practices, ingredients used, and portion sizes. This information is crucial in determining how to modify the traditional foods to fit the client's meal plan. Providing a printed recipe (A) may not consider the client's cultural preferences or cooking methods. Using cookbooks (C) may not align with the client's traditional foods or cooking techniques. Explaining the diabetes exchange list (D) is important but should come after understanding the client's current food habits.
A community health nurse is providing teaching to a group of clients who have alcohol use disorder. Which of the following findings should the nurse include in the teaching as a manifestation of alcohol withdrawal?
- A. Bradycardia
- B. Hypothermia
- C. Increased appetite
- D. Insomnia
Correct Answer: D
Rationale: The correct answer is D: Insomnia. Alcohol withdrawal commonly presents with symptoms such as difficulty sleeping, restlessness, and anxiety due to the disruption of the central nervous system. Insomnia is a hallmark manifestation of alcohol withdrawal syndrome. Bradycardia (A) is not typically associated with alcohol withdrawal; instead, tachycardia is more common. Hypothermia (B) is rare in alcohol withdrawal, as alcohol tends to cause vasodilation and can lead to increased body temperature. Increased appetite (C) is not a typical symptom of alcohol withdrawal; in fact, decreased appetite or nausea is more common. Therefore, the correct choice is D based on the typical manifestations of alcohol withdrawal.