# Stage 3 — Prioritize hypotheses. Mrs. L, who lives alone, is being discharged today on two new insulins: glargine nightly and lispro with meals. Vietnamese is her preferred healthcare language, and she says she cannot discuss medicines safely in English. Admission documents were completed through her son because the qualified-interpreter line had a 30-minute wait. Vital signs are normal, and prebreakfast glucose is 142 mg/dL after resolution of the acute hyperglycemic crisis. She is alert and oriented and answers questions with repeated yes responses but does not explain the plan in her own words. When asked about low glucose, her son says she understands instead of interpreting her answer. No independent insulin-pen or glucose-meter demonstration is documented. Complete the diagram by selecting the condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress. > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=617397&lang=en > language: en > subject: Assignment/Delegation/Supervision > category: MOC ## Question Stage 3 — Prioritize hypotheses. Mrs. L, who lives alone, is being discharged today on two new insulins: glargine nightly and lispro with meals. Vietnamese is her preferred healthcare language, and she says she cannot discuss medicines safely in English. Admission documents were completed through her son because the qualified-interpreter line had a 30-minute wait. Vital signs are normal, and prebreakfast glucose is 142 mg/dL after resolution of the acute hyperglycemic crisis. She is alert and oriented and answers questions with repeated yes responses but does not explain the plan in her own words. When asked about low glucose, her son says she understands instead of interpreting her answer. No independent insulin-pen or glucose-meter demonstration is documented. Complete the diagram by selecting the condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress. Condition Select 1 Unsafe self-management from inadequate language access Cognitive impairment limiting self-management Recurrent hyperosmolar hyperglycemic state Intentional refusal of the insulin plan Actions to take Select 2 Ask the son to translate the discharge teaching Give the Vietnamese handout and obtain her signature Arrange a qualified medical interpreter Have her teach back and demonstrate pen and meter Request cognitive screening before any teaching Parameters to monitor Select 2 Mini-Cog screening score Teach-back accuracy on insulin doses Serum osmolality and sodium levels Hemoglobin A1C at the follow-up visit Home blood glucose log values ## Explanation Mrs. L is alert and clinically stable, but she cannot discuss medicines in English, her son summarizes instead of interpreting, and she has never demonstrated her insulin or meter, so the problem is unsafe self-management from inadequate language access. The nurse arranges a qualified medical interpreter and has her teach back and demonstrate the pen and meter. Teach-back accuracy and her home glucose log show whether the plan is being carried out safely. ## In-depth explanation Quick answer Condition: unsafe self-management from inadequate language access. Actions: arrange a qualified (Vietnamese) medical interpreter and have her teach back and demonstrate pen and meter. Monitor: teach-back accuracy on insulin doses and home blood glucose log values. Why this is correct Two insulins with different timing, living alone, and no demonstrated skill make this a high-risk discharge. Every piece of evidence that she understands has passed through someone else: the son completed admission documents and now answers for her, and 'yes' without explanation does not show comprehension. A qualified interpreter lets her speak for herself; teach-back and return demonstration prove she can do it. After discharge, her glucose log (read back through an interpreter) shows whether she is dosing safely. Easy analogy or mental picture Teaching through a family summary is like checking a bridge by asking a passer-by whether it looks fine; teach-back through an interpreter is driving the truck across while you watch. Memory hook Her language, her words, her hands: interpreter, teach-back, return demonstration. NCLEX decision rule When comprehension of a high-risk self-care task has not been shown, provide a qualified interpreter and verify with teach-back and demonstration before discharge; a signature or family assurance is not evidence. Why the other choices are wrong Cognitive impairment is tempting because of the vague yes responses, but she is alert and oriented and the barrier is language, so a Mini-Cog or cognitive screen targets the wrong problem and delays teaching. Recurrent hyperosmolar hyperglycemic state is excluded by normal vital signs and glucose 142 mg/dL, so serum osmolality is not the progress marker. Intentional refusal is not supported; she has never had a real chance to discuss the plan. Family members are not qualified interpreters for high-risk teaching and filter what she says. A handout and signature do not show that she can draw up and time two insulins. Hemoglobin A1C changes over months and cannot show safe dosing in the first days at home. References 1HHS Office for Civil Rights — Section 1557 of the Affordable Care ActLanguage assistance through qualified interpreters for individuals with limited English proficiency 2AHRQ — Health Literacy Universal Precautions Toolkit: Use the Teach-Back MethodTeach-back to confirm understanding of self-management instructions ## Clinical scenario Case update Discharge day: two new insulins, living alone, limited English, family-mediated communication, and no demonstrated self-management. ## Key concepts - **Qualified medical interpreter** — A trained interpreter who conveys meaning accurately and impartially; family members generally do not meet this standard. - **Teach-back** — The client explains the plan in their own words so the nurse can confirm understanding and correct gaps. - **Return demonstration** — The client performs a skill, such as using an insulin pen, while the nurse observes. ## Related questions - [A 67-year-old client with chronic obstructive pulmonary disease attends a routine primary …](https://mymerci.kr/pages/nclex_q.php?qn_id=360522&lang=en) - [A registered nurse on a medical-surgical unit is delegating tasks at the start of shift. 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