Nokea
A nurse is caring for a patient with limited English proficiency. What action should the nurse take to ensure effective communication with the patient?
- A. Speak loudly and slowly to help the patient understand
- B. Use medical jargon to convey information more efficiently
- C. Obtain interpreter services or language assistance as needed
- D. Ignore the patient's language barriers and focus on nonverbal communication
Correct Answer: C
Rationale: The nurse should obtain interpreter services or language assistance as needed to ensure effective communication with a patient who has limited English proficiency. Using an interpreter will facilitate clear and accurate communication between the nurse and the patient, enabling the patient to fully understand their care, treatment, and any instructions provided. Speaking loudly or slowly, using medical jargon, or ignoring the language barriers are not effective strategies for communicating with a patient who has limited English proficiency. Utilizing interpreter services demonstrates respect for the patient's language and cultural needs, which is essential for providing high-quality care.
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Which clinical manifestation should Nurse Rachel watch for patient Claire if she is suffering from hyperthyroidism?
- A. Cold extremities
- B. Decreased bowel movement
- C. Fine motor tremor
- D. Increased weight
Correct Answer: C
Rationale: Hyperthyroidism is a condition where the thyroid gland produces an excess amount of thyroid hormone. One of the clinical manifestations of hyperthyroidism is a fine motor tremor, which is characterized by hand tremors or shaky movements in the fingers. This tremor is often more noticeable when the individual is trying to perform delicate tasks requiring fine motor skills. It is important for Nurse Rachel to watch for this symptom in patient Claire as it can impact her ability to perform daily activities and may require intervention or management strategies to help alleviate the tremor and improve quality of life.
Which of the following is the INITIAL eaching given to the patient with ALS and her family?
- A. Referral to support group
- B. Prevention of complications
- C. Explaining the disease process, expected course and prognosis
- D. Prevention of depression
Correct Answer: C
Rationale: The initial teaching given to a patient with ALS and her family should focus on explaining the disease process, the expected course, and prognosis. Providing this information early on can help the patient and her family understand what to expect, make informed decisions about care and treatment, and prepare emotionally for the challenges ahead. It is important to establish open communication and provide support from the beginning to help the patient and her family cope with the diagnosis and navigate the journey with ALS. While referral to support groups, prevention of complications, and prevention of depression are all important aspects of care for ALS patients, understanding the disease process and prognosis is fundamental to setting realistic expectations and planning for the future.
A postpartum client who had an episiotomy expresses concern about the appearance and healing of the incision site. What nursing intervention should be prioritized to promote optimal wound healing?
- A. Encouraging frequent perineal hygiene with soap and water
- B. Applying antibiotic ointment to the incision site after each void
- C. Providing perineal care using peri-bottles with warm water
- D. Instructing the client on proper peri-pad application to the incision
Correct Answer: C
Rationale: The priority nursing intervention to promote optimal wound healing in a client who had an episiotomy is providing perineal care using peri-bottles with warm water. Warm water helps to cleanse the area, reduce the risk of infection, and promote circulation, which aids in wound healing. Peri-bottles are especially gentle and effective in cleaning the perineal area without causing trauma to the incision site. Encouraging frequent perineal hygiene with soap and water may be too harsh on the incision site and could lead to irritation. Applying antibiotic ointment after each void is not necessary unless prescribed by the healthcare provider, as overuse of antibiotics can lead to resistance. Instructing the client on proper peri-pad application is important for comfort and cleanliness but is not as crucial as gentle perineal care using peri-bottles with warm water for promoting optimal wound healing.
Nursing diagnosis commonly used when working with Sandro is
- A. ineffective role performance
- B. Compromised family coping
- C. impaired social interaction
- D. risk for injury.
Correct Answer: C
Rationale: When working with Sandro, who is taking an MAOI and needs to be educated on avoiding foods with tyramine, the nursing diagnosis commonly used would be "impaired social interaction." This nursing diagnosis focuses on the client's difficulty in establishing or maintaining meaningful relationships with others. In this case, Sandro's dietary restrictions due to his medication may cause challenges in social situations, leading to potential feelings of isolation or inability to engage in social activities involving food. By identifying impaired social interaction as a nursing diagnosis, the nurse can address these issues and support Sandro in maintaining social connections while adhering to his dietary requirements.
When communicating with a patient from a different cultural background, what should the nurse prioritize?
- A. Ignoring cultural differences to avoid making the patient uncomfortable.
- B. Using medical jargon to ensure clarity and precision.
- C. Recognizing and respecting the patient's cultural beliefs and practices.
- D. Minimizing the time spent communicating with the patient.
Correct Answer: C
Rationale: When communicating with a patient from a different cultural background, the nurse should prioritize recognizing and respecting the patient's cultural beliefs and practices. This is essential in providing culturally competent care, fostering trust and rapport with the patient, and ultimately improving health outcomes. By acknowledging and understanding the cultural context of the patient, the nurse can adapt communication strategies, address the patient's needs effectively, and avoid misunderstandings or misinterpretations. Building a culturally sensitive approach can enhance the quality of care and strengthen the therapeutic relationship between the nurse and patient.