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. "I will drink half of a cup of fruit juice when I feel shaky and weak.": Shakiness and weakness are early signs of low blood glucose, and consuming 15 grams of a fast-acting carbohydrate like ½ cup of fruit juice is an appropriate immediate response.

B. "I will soak my feet in water before applying lotion between my toes.": Diabetic clients should avoid soaking their feet due to the risk of skin maceration and infection. Lotion should not be applied between the toes, as this can promote fungal growth in a moist environment.

C. "I will skip a snack if I'm not hungry after lunch.": Skipping snacks can lead to hypoglycemia, especially if insulin has been administered. Even when not hungry, small carbohydrate intake may be necessary depending on the insulin regimen and activity level.

D. "I will only go without socks and shoes when I am in my home.": Diabetic clients should always wear protective footwear, even at home, to avoid undetected foot injuries that can lead to ulcers or infections due to impaired sensation and circulation.

A. Ask an experienced nurse to assist with the procedure. B. Delegate the task to an assistive personnel. C. Refuse to take the assignment. D. Identify that the task is in the scope of RN practice and perform the suctioning.

Correct Answer is A

Explanation

Rationale:

A. Ask an experienced nurse to assist with the procedure: Seeking guidance from an experienced nurse supports safe practice and skill development. It ensures the procedure is performed correctly while providing an opportunity for supervised learning, which is appropriate for a newly licensed nurse.

B. Delegate the task to an assistive personnel: Tracheal suctioning is a sterile and invasive procedure that requires the clinical judgment and skills of a registered nurse. It should not be delegated to assistive personnel who are not trained or licensed to perform such procedures.

C. Refuse to take the assignment: Refusing the assignment without attempting to seek help or learn is not a constructive or professional approach. Nurses are expected to seek support when performing unfamiliar but appropriate tasks within their role.

D. Identify that the task is in the scope of RN practice and perform the suctioning: While it is within the RN scope, performing a skill without training or supervision may compromise patient safety. Competence must be demonstrated or developed with supervision before performing independently.

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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

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