A nurse is obtaining a health history from an adolescent who they suspect is experiencing physical maltreatment. Which of the following actions should the nurse take?

Make an audio recording of the adolescent's responses

Promise not to disclose information shared during the interview

Obtain a history from both the adolescent and their caregiver.

Use leading questions during the interview.

Answer and Explanation

The Correct Answer is C

Rationale:

A. Make an audio recording of the adolescent's responses: Audio recordings require consent and may not be legally or ethically appropriate in suspected abuse cases. Documentation should be written, factual, and follow institutional policies and mandatory reporting laws.

B. Promise not to disclose information shared during the interview: Nurses must never promise confidentiality in suspected abuse cases, as they are mandated reporters. All disclosures of abuse must be reported to child protective services or appropriate authorities.

C. Obtain a history from both the adolescent and their caregiver: Gathering information from both parties helps identify inconsistencies and assess the situation fully. However, this should be done separately to allow the adolescent to speak freely and without coercion.

D. Use leading questions during the interview: Leading questions can influence the adolescent’s responses and compromise the integrity of the assessment. Open-ended, nonjudgmental questions are essential to support accurate and unbiased information gathering.

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Correct Answer is A

Explanation

Rationale:

A. Administer diuretics: The client's symptoms, moist lung sounds, bounding pulse, elevated blood pressure, and pitting edema indicate fluid volume overload. Administering prescribed diuretics is the priority intervention to rapidly reduce intravascular and interstitial fluid volume and relieve pulmonary congestion.

B. Limit the client's fluid intake: Fluid restriction helps manage ongoing fluid retention but does not address the immediate concern of volume overload. It is a supportive measure rather than the initial priority in acute decompensated heart failure.

C. Insert an indwelling urinary catheter: While catheterization may help monitor output, it does not treat the underlying fluid excess. Inserting a catheter without addressing the fluid accumulation first does not provide immediate symptom relief.

D. Place the client on a low-sodium diet: A low-sodium diet is important for long-term management of heart failure, but it does not provide the prompt fluid removal needed in this acute situation. Immediate diuresis is necessary to reduce cardiac workload and respiratory distress.

A. Fibrocystic breast condition B. Hypertension C. Fibromyalgia D. Asthma

Correct Answer is B

Explanation

Rationale:

A. Fibrocystic breast condition: This benign breast disorder does not interfere with the use of oral contraceptives. In fact, hormonal birth control may sometimes reduce breast pain and nodularity associated with this condition.

B. Hypertension: High blood pressure is a known contraindication for oral contraceptive use, especially if it is uncontrolled. Estrogen-containing contraceptives can further elevate blood pressure and increase the risk of cardiovascular events such as stroke or myocardial infarction.

C. Fibromyalgia: Fibromyalgia does not interact with oral contraceptives and is not a contraindication. While hormonal changes may influence pain perception, there is no direct risk in using contraceptives for someone with this condition.

D. Asthma: Asthma is not a contraindication to using oral contraceptives. There is no evidence that hormonal contraceptives worsen asthma symptoms or interfere with its management.

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A nurse is obtaining a health history from an adolescent who they suspect is experiencing physical maltreatment. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has heart failure. The client has moist lung sounds, bounding pulse, increased blood pressure, and pitting peripheral edema. Which of the following is the nurse's priority intervention?

Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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