A Russian immigrant created a disturbance while at a funeral. This person was loud, mixed English and Russian phrases, and made dramatic gestures. Police take the person to the emergency department. The nurse assessing this person should:
a. defer the nursing assessment interview until after the person has calmed down.
b. say, "I am going to ask you some questions. Try to answer in English."
c. request a security guard be available during the assessment.
d. request assistance by an interpreter.
D
An English-speaking nurse who does not speak the other language cannot accurately assess a person who is mixing English with another native language. Accurate assessment data is vital; hence, calling for an interpreter is necessary and expedient. Hospitals have access to individuals who are fluent in various languages. Deferring the interview should not be an initial option. Data do not suggest the patient is aggressive, although dramatic gestures may be interpreted as aggression in some cultural contexts.
You might also like to view...
A parent reports that her 5-year-old child, who has had all recommended immunizations, had a mild fever one week ago and now has bright red cheeks and a lacy red maculopapular rash on the trunk and arms
The nurse recognizes that this child might have: 1. Chickenpox (varicella). 2. German measles (rubella). 3. Roseola (exanthem subitum). 4. Fifth disease (erythema infectiosum).
The primary purpose of priming all IV tubing before connecting it to the client is to:
a. prevent air embolism. b. ensure that an accurate dose of medication is delivered. c. aid in the solution flow through an infusion device. d. establish flow rate.
A patient complains of difficulty falling asleep and daytime fatigue for the past 6 weeks. What is the best initial action for the nurse to take in determining whether this patient has chronic insomnia?
a. Schedule a polysomnography (PSG) study. b. Arrange for the patient to have a sleep study. c. Ask the patient to keep a 2-week sleep diary. d. Teach the patient about the use of an actigraph.
While caring for an older adult male, the nurse observes that his skin is dry and wrinkled, his hair is gray, and he needs glasses to read. Based on these observations, what would the nurse conclude?
A) These are normal physiologic changes of aging. B) The observations are not typically found in older adults. C) These are abnormal observations and must be reported. D) Extra education will be necessary to prevent complications.