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 B

Explanation

Rationale:

A. "You should expect your blisters to last up to three weeks.": Herpes zoster lesions typically last 7 to 10 days, with crusting and healing often occurring within 2 weeks. While some cases may extend slightly longer, stating "up to three weeks" may overgeneralize and mislead.

B. "Antiviral medications are most effective if taken within the first 72 hours of symptoms.": Antiviral drugs like acyclovir or valacyclovir are most effective when initiated within 72 hours of symptom onset. Early treatment reduces severity, duration, and the risk of complications such as postherpetic neuralgia.

C. "People who have had chicken pox are at a decreased risk for herpes zoster.": Herpes zoster occurs due to reactivation of the varicella-zoster virus, which remains dormant after chickenpox. Therefore, individuals who have had chickenpox are actually at increased risk.

D. "Severe pain after the blisters are gone is less common in older adults.": Older adults are more likely to experience postherpetic neuralgia, a complication involving persistent nerve pain after lesions resolve. The risk and severity of this pain increase with age, not decrease.

A. Providing the client with information about transportation services. B. Informing the client about providers who accept their health insurance. C. Arranging an appointment for the client with a mobile health clinic. D. Encouraging the client to become a self-advocate.

Correct Answer is C

Explanation

Rationale:

A. Providing the client with information about transportation services: This helps address access barriers but focuses on support services rather than directly organizing or integrating healthcare delivery, which is central to coordination of care.

B. Informing the client about providers who accept their health insurance: While helpful, this action centers on financial guidance. It supports access but does not actively bridge or organize care among multiple services or settings.

C. Arranging an appointment for the client with a mobile health clinic: Coordinating an appointment directly connects the client with needed services, especially in underserved rural areas. This reflects active care coordination by ensuring timely access to care and reducing system fragmentation.

D. Encouraging the client to become a self-advocate: Promoting self-advocacy empowers the client in their health journey but does not represent coordination of care. Coordination involves organizing and facilitating access across providers and settings.

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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

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Correct Answer is B

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Correct Answer is C

Explanation

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