The nurse is caring for a patient who is a recent immigrant and has limited English proficiency. Which of the following is the best action the nurse should take?
- A. Use medical jargon to explain the procedure to ensure the patient understands.
- B. Speak loudly and slowly to make sure the patient understands.
- C. Use a professional interpreter or translation services to communicate effectively.
- D. Ask the patient's family to translate for the nurse.
Correct Answer: C
Rationale: The correct answer is C: Use a professional interpreter or translation services to communicate effectively. This is the best action because it ensures accurate communication and understanding between the nurse and the patient. Professional interpreters are trained to accurately convey information while respecting cultural nuances.
Explanation for why the other choices are incorrect:
A: Using medical jargon can confuse the patient further and hinder effective communication.
B: Speaking loudly and slowly can come across as patronizing and does not address the language barrier.
D: Relying on the patient's family for translation can lead to miscommunication or breaches of patient confidentiality.
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A 47-year-old woman who is a recent immigrant to Canada is being seen at the clinic today for her uncontrolled diabetes. The nurse knows that the patient lives with her husband and a large extended family. The nurse concludes that part of the patient's inability to maintain and comply with her diet and diabetic regime is the foods that this patient eats. This conclusion is an example of:
- A. cultural sensitivity.
- B. cultural safety.
- C. cultural perspective.
- D. culturalism.
Correct Answer: D
Rationale: The correct answer is D: culturalism. The nurse's conclusion that the patient's inability to maintain her diet and diabetic regime is due to the foods she eats reflects culturalism. Culturalism refers to the belief that a person's behaviors and beliefs are solely determined by their culture. In this case, the nurse is attributing the patient's struggles solely to her cultural background without considering other factors.
A: Cultural sensitivity is about being aware and respectful of different cultures, but it does not involve making assumptions based on culture alone.
B: Cultural safety is about creating a safe and respectful environment for individuals from different cultures, but it does not involve making assumptions about behavior solely based on culture.
C: Cultural perspective involves understanding different cultural viewpoints, but it does not involve making assumptions about behavior solely based on culture.
In summary, the nurse's conclusion is an example of culturalism as it oversimplifies the patient's situation by attributing her struggles solely to her cultural background.
What should be the nurse's first action when caring for a client who has a suspected stroke?
- A. Assess the client's airway
- B. Administer oxygen
- C. Administer aspirin
- D. Perform a CT scan
Correct Answer: A
Rationale: The correct answer is A: Assess the client's airway. This is the first action because airway patency is the top priority in any emergency situation, including a suspected stroke. Ensuring the client can breathe effectively is crucial to prevent hypoxia and further complications. Administering oxygen (choice B) may be necessary after assessing the airway. Administering aspirin (choice C) should be done after a definitive diagnosis of an ischemic stroke. Performing a CT scan (choice D) is important for diagnosis but is not the first action to take in a suspected stroke scenario.
What is the first intervention when a client develops symptoms of shock?
- A. Administer oxygen
- B. Administer IV fluids
- C. Monitor respiratory rate
- D. Administer pain medication
Correct Answer: A
Rationale: The correct answer is A: Administer oxygen. Oxygen administration is the first intervention for shock as it helps improve oxygenation to vital organs. Lack of oxygen can worsen shock. Administering IV fluids (choice B) could be the second step to improve perfusion. Monitoring respiratory rate (choice C) is important but not the first intervention. Administering pain medication (choice D) is not a priority in managing shock.
What assessment framework provides additional modesty for clients, such as teenage girls?
- A. Body systems
- B. Functional
- C. Focused
- D. Head to toe
Correct Answer: D
Rationale: The correct answer is D: Head to toe. This assessment framework allows for modesty by assessing one body part at a time, starting from the head down to the toe. This approach ensures clients, especially teenage girls, feel comfortable and respected during the assessment process. Other choices like A (Body systems) involve assessing multiple body parts simultaneously, potentially compromising modesty. Functional assessment (B) focuses on assessing specific functions rather than individual body parts, which may not address the modesty concern. Focused assessment (C) targets a specific area of concern, which may not provide a comprehensive evaluation while also potentially overlooking modesty concerns.
Which technique should the nurse use to determine the presence of crepitus during a physical examination?
- A. Percussion
- B. Auscultation
- C. Palpation
- D. Auscultation
Correct Answer: A
Rationale: The correct technique to determine the presence of crepitus during a physical examination is palpation. Crepitus is a crackling or grating sensation that is felt when there is air trapped in the subcutaneous tissue. Palpation involves using the hands to feel for abnormalities such as crepitus. Percussion involves tapping on the body to produce sounds that can help assess underlying structures, not to determine the presence of crepitus. Auscultation is listening to sounds within the body using a stethoscope, which is not relevant for detecting crepitus.