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. Canned black beans: While black beans are a healthy source of protein and fiber, canned varieties are often high in sodium unless labeled low-sodium. High sodium intake can worsen hypertension, so these should be limited or thoroughly rinsed before use.

B. Fish: Fish, particularly those high in omega-3 fatty acids like salmon and mackerel, can help lower blood pressure and reduce cardiovascular risk. They are a heart-healthy protein source recommended in hypertension management.

C. Red meat: Red meat is often high in saturated fat and cholesterol, which can contribute to elevated blood pressure and heart disease. It should be limited in a diet designed to control hypertension.

D. Cheese: Many cheeses are high in sodium and saturated fat, which can increase blood pressure and cardiovascular strain. Even small portions may contain significant sodium, making them less ideal for clients with hypertension.

A. Encourage the client and partner to avoid expressing negative feelings about the colostomy. B. Suggest the client join a support group for people who have colostomies. C. Instruct the client's partner to assume care of the colostomy for the client. D. Transfer the client to a rehabilitation facility for instruction about self-management of the colostomy.

Correct Answer is B

Explanation

Rationale:

A. Encourage the client and partner to avoid expressing negative feelings about the colostomy: Suppressing negative emotions can hinder psychological adjustment. Clients should be encouraged to express their feelings openly as part of the adaptation and coping process.

B. Suggest the client join a support group for people who have colostomies: Support groups can provide emotional reassurance, shared experiences, and practical coping strategies. Seeing others manage their stomas successfully can promote acceptance and self-confidence.

C. Instruct the client's partner to assume care of the colostomy for the client: While partner support is important, encouraging dependence may delay the client’s adjustment and self-care ability. The goal should be to promote independence and acceptance at the client’s pace.

D. Transfer the client to a rehabilitation facility for instruction about self-management of the colostomy: A transfer is not necessary unless the client has complex needs. Initial support, education, and emotional guidance should be provided in the current care setting.

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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?

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