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 B

Explanation

A: Ensure that the room is warm and undress the child completely. While a warm room is important to keep the child comfortable, undressing the child completely can cause distress and discomfort, especially in toddlers who may feel exposed and vulnerable.

B: Have the parent remove the child's outer clothing and remove the diaper or training pants when necessary. This approach is more appropriate as it allows the child to remain relatively comfortable and secure. The parent’s involvement helps reassure the child, and only removing necessary clothing minimizes distress. It also allows for targeted examination without fully undressing the child, which is less intimidating for toddlers.

C: Help the child take off his/her clothes, removing underwear only to conduct examination of the genitalia. Assisting the child in removing clothes can be helpful, but it might be more comforting and less invasive if the parent is involved in this process. Removing underwear only when necessary for a genital examination is appropriate, but it might still be distressing for the child without prior explanation and parental presence.

D: Prior to helping the child remove his/her clothing, use a paper doll to demonstrate removal of clothing. Demonstrating the process using a paper doll can be an effective way to prepare the child for what will happen during the assessment, reducing anxiety. However, this is more of a preparatory step rather than a direct protocol for the physical assessment itself. It can be a helpful adjunct to the primary method but is not sufficient on its own.

A. Eats less salt-cured meats. B. Participates in healing rituals. C. Uses herbal remedies. D. Meditates in sweat lodges.

Correct Answer is C

Explanation

A. Eats less salt-cured meats: Reducing the intake of salt-cured meats is generally a positive behaviour, especially for someone with hypertension. This behaviour aligns with dietary recommendations for managing high blood pressure.

B. Participates in healing rituals: Healing rituals are part of many cultural practices and can provide emotional and spiritual support. However, without further information, it's unclear if these rituals interfere with the prescribed treatment. This may warrant additional assessment to ensure they complement the medical regimen.

C. Uses herbal remedies: The use of herbal remedies could potentially interact with prescribed antihypertensive medications. This behaviour requires careful assessment to ensure there are no harmful interactions or adverse effects on the treatment plan.

D. Meditates in sweat lodges: Sweat lodges are a traditional practice for many Native Americans, providing physical and spiritual cleansing. However, the high temperatures and dehydration risks associated with sweat lodges could adversely affect blood pressure control and overall cardiovascular health. This behaviour requires further evaluation to ensure it is safe for the client with hypertension.

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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

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