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 reviewing recommended dietary modifications with a client with celiac disease. Which of the following menu selections by the client would indicate a correct understanding of the teaching? Select all that apply.
- A. Beef barley soup with mixed vegetables and French bread
- B. Corn tortilla tacos with ground beef and cheese
- C. Grilled chicken, baked potato, and strawberry yogurt
- D. Peanut butter and jelly on whole wheat bread and an apple
- E. Rice noodles with chicken and broccoli
Correct Answer: B,C,E
Rationale: Corn tortillas, grilled chicken with potato/yogurt, and rice noodles are gluten-free, suitable for celiac disease. Barley and wheat contain gluten.
A 4-year old is scheduled for a routine tonsillectomy. Which of the following lab findings should be reported to the doctor?
- A. A hemoglobin of $12 \mathrm{gm}$
- B. A platelet count of $200,000 \mathrm{cu} \mathrm{mm}$
- C. A white cell count of $16,000 \mathrm{cu} \mathrm{mm}$
- D. A urine specific gravity of 1.010
Correct Answer: C
Rationale: A white cell count of 16,000 is elevated, suggesting infection, which must be reported before surgery. Hemoglobin , platelets , and urine specific gravity are normal.
The nurse is conducting intake interviews at the clinic. Which client situations would require the nurse to intervene? Select all that apply.
- A. Client with iron deficiency anemia takes iron supplements with milk
- B. Client takes levothyroxine early in the morning on an empty stomach
- C. Client taking phenazopyridine for urine infection states that the urine has turned orange
- D. Client taking metronidazole mentions going to a wine-tasting party tonight
- E. Client with closed-angle glaucoma takes over-the-counter diphenhydramine for a cold
Correct Answer: A,D,E
Rationale: Milk reduces iron absorption, metronidazole with alcohol can cause severe reactions, and diphenhydramine can worsen closed-angle glaucoma.
A female client is admitted for a breast biopsy. She says, tearfully to the nurse, 'If this turns out to be cancer and I have to have my breast removed, my partner will never come near me.' The nurse's best response would be which of these statements?
- A. I hear you saying that you have a fear for the loss of love.'
- B. You sound concerned that your partner will reject you.'
- C. Are you wondering about the effects on your sexuality?'
- D. Are you worried that the surgery will lead to changes?'
Correct Answer: D
Rationale: This is a general lead-in type of response that encourages further discussion without focusing on an area that the nurse, but possibly not the client, feels is a problem.
The nurse is reinforcing teaching to a client diagnosed with Raynaud phenomenon about ways to prevent recurrent episodes. Which instructions should the nurse include? Select all that apply.
- A. Avoid excess caffeine
- B. Immerse hands in cold water
- C. Practice yoga or tai chi
- D. Refrain from using tobacco products
- E. Wear gloves when handling cold objects
Correct Answer: A,C,D,E
Rationale: Caffeine, tobacco, and cold exposure can trigger Raynaud episodes. Yoga/tai chi and gloves help prevent attacks. Cold water immersion exacerbates symptoms.