A nurse is planning care for a patient from a culture where family involvement is critical in health decisions. What should the nurse do to ensure cult competent care?

Rationale:

A. Document the result in the electronic health record with restricted access is correct because maintaining confidentiality for an adolescent client is essential, especially regarding sensitive health information such as pregnancy status. Nurses must follow legal and institutional policies that allow restricted access to sensitive information while ensuring appropriate care. This respects the adolescent’s privacy and supports trust in the nurse-client relationship.

B. Inform the parents immediately is incorrect because disclosing sensitive information without the adolescent’s consent violates confidentiality rights. In many jurisdictions, adolescents have the legal right to confidential reproductive health services.

C. Ask the client to inform their parents is partially correct but insufficient on its own. While encouraging voluntary disclosure can be appropriate, the nurse’s primary responsibility is to maintain confidentiality and provide care without pressuring the client.

D. Discuss the result with the entire healthcare team is incorrect because sharing sensitive information with all team members is unnecessary and breaches confidentiality. Only professionals directly involved in the adolescent’s care and with a need to know should have access, and access should be limited.

Rationale:

A. Conducting regular screenings for early detection of burn injuries is incorrect because this is secondary prevention, which focuses on early detection and intervention to reduce the severity of a disease or injury. Screening identifies problems before they become more serious but does not manage long-term complications.

B. Administering pain management and wound care to a burn victim is correct because tertiary prevention aims to reduce complications, manage long-term consequences, and improve quality of life after an injury or illness has occurred. In burn care, interventions like wound care, pain management, physical therapy, and rehabilitation prevent further disability, promote healing, and restore function, which are hallmarks of tertiary prevention.

C. Educating patients on fire safety to prevent burns is incorrect because this is primary prevention, which focuses on preventing injury or illness before it occurs. Fire safety education reduces the risk of burn injuries in the community.

D. Organizing community workshops on proper nutrition is incorrect because nutrition education is a primary prevention strategy aimed at maintaining health and preventing disease rather than managing or reducing complications after an injury.