When-obtaining an adolescent's health history, which intervention is most important of the nurse to implement?

Assess for the use of illicit drugs.

Obtain a smoking history first.

Evaluate vital signs and laboratory findings.

Ask the parents to leave the room.

Answer and Explanation

The Correct Answer is D

A. Assess for the use of illicit drugs. While assessing illicit drug use is important, it may not be the most crucial intervention during the initial health history-taking process.

B. Obtain a smoking history first. While obtaining a smoking history is important, it may not take precedence over other aspects of the health history, especially if there are more pressing concerns.

C. Evaluate vital signs and laboratory findings. While vital signs and laboratory findings are important components of the assessment, they are typically obtained after the health history has been completed.

D. Ask the parents to leave the room. Ensuring privacy and confidentiality is crucial during adolescent health assessments to encourage open communication and address sensitive issues. Asking the parents to leave the room allows the adolescent to speak freely about their health concerns without fear of judgment or disclosure to their parents.

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Correct Answer is C

Explanation

A. Obtain a dietary consultation for nutrition teaching: Diet might play a role in some thyroid conditions, but a referral for dietary consultation wouldn't be the first step.

B. Instruct the client in the need to use iodized salt: Iodine deficiency can cause goiter (enlarged thyroid gland), but most table salt in developed countries is iodized.

C. Request diagnostic laboratory testing for the client: This is the most appropriate next step. Blood tests can help determine the cause of the enlarged thyroid gland.

D. Schedule a follow-up appointment in one month: A follow-up might be needed, but further workup is essential to determine the cause of the finding.

A. Blue tinge in the nail beds. B. Ashen grey tone to lips. C. Ashy yellow appearance of skin. D. Reddish purple colored palms.

Correct Answer is A

Explanation

A. Blue tinge in the nail beds: This finding is indicative of cyanosis. When oxygen levels in the blood are low, the skin and mucous membranes may appear bluish due to inadequate oxygenation. The nail beds are a common area to observe this bluish discoloration.

B. Ashen grey tone to lips: While this can be concerning, it is not a classic sign of cyanosis. Ashen grey lips may be associated with other conditions, such as shock or poor perfusion, but they do not specifically indicate cyanosis.

C. Ashy yellow appearance of skin: This finding is not related to cyanosis. An ashy yellow appearance may be seen in conditions like liver disease or jaundice, but it does not reflect oxygenation status.

D. Reddish purple colored palms: Again, this is not a sign of cyanosis. Reddish or purple palms may be seen in various conditions, but they do not specifically point to inadequate oxygen levels.

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When-obtaining an adolescent's health history, which intervention is most important of the nurse to implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When performing a physical assessment, palpation reveals to the clinic nurse that a client has an enlarged thyroid gland. What action should the nurse take in response to this finding?

Correct Answer is C

Explanation

The nurse is assessing a darkly pigmented child for cyanosis. Which finding indicates cyanosis?

Correct Answer is A

Explanation

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