341 Ch 7
The nurse is assessing an adolescent's risk for harm from guns being present in the home. What question would be best to ask during the assessment? "Have you been taught how to use a gun?" "Are the guns in your home locked in a safe?" "Do you and your dad hunt?" "Do you understand that it is important for you not to handle a gun?"
"Are the guns in your home locked in a safe?"
A 16-year-old girl has arrived for her sports physical with a new piercing in her navel. Which response by the nurse is best? "This is a wound and can become infected." "I hope for your sake the needle was clean." "Be sure to clean the navel several times a day." "This is a risk for hepatitis, tetanus, and AIDS."
"Be sure to clean the navel several times a day."
A high school athlete comes to the emergency department with hypertension, aggressiveness, and psychosis. What question would be important for the nurse to ask the client? "Do you take anabolic steroids?" "Do you take human growth hormone?" "Do you take cocaine?" "Do you take amphetamines?"
"Do you take anabolic steroids?" Anabolic steroids are used by adolescents who play sports. They are used to enhance the adolescent's athletic ability. They produce euphoria and lessened fatigue. Unfortunately, steroid use can also lead to early closure of the epiphyseal plate, acne, elevated triglyceride levels, hypertension, aggressiveness, and possibly psychosis. Human growth hormone is also used to enhance athletic performance. The side effects of it are joint pain and swelling and the development of diabetes. Amphetamines provide a sense of well-being, alertness, and self-esteem. They can produce paranoia and extreme restlessness. Cocaine produces increased pulse and respirations, increased temperature, and blood pressure and decreased appetite.
The nurse is caring for an 11-year-old girl. The girl's mother reports that the girl does not want to play team sports like soccer or volleyball anymore. Her daughter insists she does not enjoy them. The mother is concerned that her daughter will not get enough physical activity and asks the nurse for guidance. How should the nurse respond? "Give her some options; it's important to find something she enjoys." "Remind her of the importance of regular physical activity for good health." "Why don't you sign her up for an aerobics or dance class?" "Organized sports are just a complementary activity to other physical activities."
"Give her some options; it's important to find something she enjoys."
A teacher refers a student to the school nurse because the student is frequently falling asleep during class. After talking with the student, the nurse is most concerned by which statement by the student? "I get 7 hours of sleep every night so I don't know why I am so tired." "My mom keeps telling me to turn off my television when I go to bed." "I just can't seem to stay awake during that class because it's boring." "I guess I need to be more careful about my curfew on school nights."
"I get 7 hours of sleep every night so I don't know why I am so tired."
The nurse is counseling an overweight, sedentary 15-year-old girl. The nurse is assisting her to make appropriate menu choices. Which statement indicates the adolescent understands how to make appropriate dietary selections? "To lose weight my protein intake should be limited to 2 to 4 servings per day." "I avoid all fat intake." "I need to have 4 servings of fruit each day." "Because of my age, my dairy intake is unlimited."
"I need to have 4 servings of fruit each day."
A 16-year-old adolescent is talking with the nurse at a local health clinic about skin care. Which comments by the teen does the nurse determine require additional conversation? Select all that apply. "I only tan before going on spring break to get a base tan so I won't burn." "Our coach makes us wear sun-protective clothes when we practice outside on the weekends." "The more exposure and burns I get now will toughen my skin so I won't get skin cancer when I'm older." "My mom had melanoma so she always makes me wear a sunscreen with an SPF of 30." "My favorite time of day to be outside is the middle of the day, around noon."
"I only tan before going on spring break to get a base tan so I won't burn." "The more exposure and burns I get now will toughen my skin so I won't get skin cancer when I'm older." "My favorite time of day to be outside is the middle of the day, around noon."
A 15-year-old client's parent comments on the fact that the adolescent seems to always choose the opposite of what everyone else wants and that mood swings are a common occurrence. What statement shows the nurse that the client's parent understands these changes? "I know that my adolescent is doing this because of all the hormones." "This is common for this age group and it will get better with time." "My adolescent will never find anyone to live with if the adolescent acts like this." "This is my adolescent's temperament, and we will have to learn how to deal with it."
"This is common for this age group and it will get better with time."
The clinic nurse is assessing a 14-year-old client. The client states "I am worried I have a brain tumor. I am so clumsy when I play sports now that it is totally embarrassing." Which response by the nurse is appropriate? "Have you noticed any changes in your vision or hearing lately?" "You are experiencing rapid and uneven growth now which can interfere with coordination." "I understand why you are worried. Has anyone else in your family had a brain tumor." "I will request the primary health care provider prescribe a magnetic resonance image (MRI)."
"You are experiencing rapid and uneven growth now which can interfere with coordination."
The school nurse is meeting with a group of 11-year-old girls to discuss expected puberty changes in their bodies. When one of the girls states, "I just feel like my whole body is changing and I don't know why" what should the nurse point out to this group? "Your other friends are feeling like this too." "You have lots of hormone changes going on right now." "You will feel better about yourself as you get older." "You may feel like you are changing, but you still look the same."
"You have lots of hormone changes going on right now."
The school nurse is assessing a 15-year-old female client. The client states, "I just want to be pretty and to look like everyone else." Which response by the nurse is appropriate? "I think you are beautiful just as you are." "Looking like everyone else is not what makes someone pretty." "Do you not think you are pretty now?" "You seem concerned. Let's talk about your feelings."
"You seem concerned. Let's talk about your feelings."
The nurse is assessing a 14-year-old male client when the client's parent jokes about the changes in the client's voice and the hair under his armpits. Which response by the nurse to the client's parent is most appropriate? "Based on your child's age, changes in hair distribution and voice pitch are expected." "It would be helpful to discuss with your child your trials with puberty and the changes you experienced." "Your child can become modest and self-conscious and teasing may cause embarrassment." "I remember that time in my life, it was so awkward and uncomfortable."
"Your child can become modest and self-conscious and teasing may cause embarrassment."
A nurse is explaining cognitive development in children to a client, with the help of Piaget's theory of cognitive development. What would be the best explanation by the nurse about the formal operations level of cognitive development? Up to age 2, children learn by touching, tasting, and feeling. They learn to control body movement. After age 12 children can think in the abstract, including complex problem solving. Children from ages 2 to 7 years investigate and explore the environment and look at things from their own point of view. From ages 7 to 11 years, children internalize actions and can perform them in the mind.
After age 12 children can think in the abstract, including complex problem solving.
A chronically ill adolescent is readmitted to the hospital with an infected wound requiring long-term dressing changes. What is the best way the nurse can encourage independence for this client? Have the adolescent go to the teen room every day. Allow the adolescent to choose the time for the dressing change. Teach the parents to perform dressing changes at home. Have the school provide homework.
Allow the adolescent to choose the time for the dressing change.
The school nurse is assessing a 16-year-old girl who was removed from class because of disruptive behavior. She arrives in the nurse's office with dilated pupils and is talking rapidly. Which drug might she be using? Opiates Barbiturates Amphetamines Marijuana
Amphetamines
The nurse is meeting with a group of caregivers of adolescents and discussing sex and sexuality, including how to discuss these issues with their children. Which comment should the nurse prioritize with this group of caregivers? Being honest and straightforward with teenagers will encourage them to ask about subjects like sexuality. Teenagers spend so much time with their peers, and that is usually how they find out about sex. Most schools have excellent programs to teach adolescents about sex and sexuality. Internet resources, movies, and television have the most accurate and current information for your adolescent to learn about sexuality issues.
Being honest and straightforward with teenagers will encourage them to ask about subjects like sexuality.
For reasons of anticipatory guidance, nurses should be aware that menarche appears earlier in some ethnic groups than others. In which ethnic group is menarche likely to appear first? Hispanic Black South Asian White
Black
A 17-year-old girl needs to increase her iron intake but is concerned about weight gain. The nurse will suggest which foods? Chicken, whole-wheat bread, watermelon Raspberry yogurt, granola, apple Cottage cheese, crackers, oranges Egg white omelet, broccoli, pear
Chicken, whole-wheat bread, watermelon
The nurse is working with a 12-year-old who has recently experienced family instability and family violence. When assessing this client in the context of Erikson's developmental theory, the nurse should recognize that the adolescent has a risk of which negative outcome? Development of an antisocial identity Dissociative identity disorder Physical and emotional aggression in relationships Confusion about role in the world
Confusion about role in the world
A nurse is taking care of a teenager who reports involuntary discharge of semen while sleeping. The nurse observes that the client is confused and does not know about the pubertal changes that are taking place in his body. Based on this information, what is the highest priority area that should be reviewed with the client? Educate the client about the changes that occur during adolescence. Review about sexually transmitted infections. Inform him that involuntary discharge of semen during sleeping needs immediate attention of the health care provider. Provide information about sex and sexuality.
Educate the client about the changes that occur during adolescence.
A 17-year-old adolescent chats excitedly with the nurse about plans for college and a career. The adolescent states having checked out every college in the region and determined which one is the best fit and would give the adolescent the best career options. The nurse recognizes which developmental aspect in this client? Identification of identity Formal operational thought Sensorimotor Socialization
Formal operational thought
The parents of a 16-year-old male are worried about recent changes in his behavior, ignoring his schoolwork and sports, and spending almost all of his free time interacting with his girlfriend. Which suggestion should the nurse point out would best address this situation? He is not developmentally mature enough to make healthy choices about the ways in which he spends his time, so it would be helpful if they would make a schedule for him that includes about a half-hour per day to talk with his girlfriend. He has chosen a girl who is overly dependent on him. They should talk to him about making sure he meets his own needs, including doing the schoolwork he enjoys, in any relationship. He is not developmentally mature enough to have an intimate relationship with one girl; they should encourage him to spend time with groups of friends rather than time alone with his girlfriend. He has developed his own identity by now; being able to establish close relationships with girls is important preparation for all of his adult relationships. They should honor his need to be with, or talk to, his girlfriend as long as he has completed his schoolwork for the day.
He has developed his own identity by now; being able to establish close relationships with girls is important preparation for all of his adult relationships. They should honor his need to be with, or talk to, his girlfriend as long as he has completed his schoolwork for the day.
What anticipatory guidance can the nurse provide the girl who has noted the development of breast buds? Breast development will be complete with 12 months. Menarche should follow in about 2 years. The growth spurt will begin immediately with menarche. Adult height will be reached at the time of menarche.
Menarche should follow in about 2 years.
A nurse is reading a journal article about adolescents and major causes of injuries in this age group. The nurse demonstrates understanding of this information by identifying which situation as the major cause of adolescent injuries? Drowning Suicide Violence Motor vehicle crashes
Motor vehicle crashes
A female client tells the nurse about noticing an increase in weight and fat deposits during the past year. The nurse reviews the client's chart and recognizes that the client is most likely going through puberty. Which nursing action is most appropriate at this time? Encourage increased exercise to control weight gain. Provide reassurance that these are normal changes. Review dietary measures to assist in controlling weight gain. Share what foods can be eaten on a low-fat diet to prevent fat deposits.
Provide reassurance that these are normal changes.
A 16-year-old client has been hospitalized 100 miles from home for 1 week to repair a fractured patella suffered in a skateboarding accident. She was cheerful and chatty when she first arrived, but the nurse notes in recent days she has become increasingly quiet and seems lonely. Which nursing intervention should the nurse prioritize for this client? Take her to the teen lounge so she can meet other teens, use a phone, and check her email. Call the hospital's mental health unit to see if she can get some counseling. Suggest that she read books and magazines from the hospital bookmobile. Ask her caregivers to bring her siblings and friends to visit.
Take her to the teen lounge so she can meet other teens, use a phone, and check her email.
An 18-year-old adolescent reveals the presence of nipple ring and is looking to get a tattoo in the next few months. What is the most important thing that the nurse can teach the adolescent at this time? Tattooing carries risks such as infection, disease, and nerve damage. Complications are more likely when you tattoo yourself. It is not recommended to get the tattoo from your friend in his garage. Review the safety rules for those who do the tattooing.
Tattooing carries risks such as infection, disease, and nerve damage.
Computer use at home and at school has increased adolescents' comfort in gaining access to and using the Internet. This has expanded their exposure to risks. What potential risks are there for an adolescent to be exposed to? Teens are at risk for identity theft from sharing personal information with others whom they do not know. Computer use can contribute to adolescent obesity due to decreased activity and increased consumption of snacks. Teens can become addicted to the online gaming and role-playing that is popular with their peers. Teens can be exposed to inappropriate materials, harassment, threats, and potential for molestation.
Teens can be exposed to inappropriate materials, harassment, threats, and potential for molestation.
The physician has made a notation in the medical record of a 17-year-old that the teen is not demonstrating successful completion of Erikson's stages of development. What behavior would be consistent with this assessment? The teen is uncertain and frequently unable to make decisions. The teen is distrustful of others. The teen is sexually promiscuous. The teen is anxious to move away from his parent's home.
The teen is uncertain and frequently unable to make decisions.
According to Erikson, the adolescent develops his or her own sense of being an independent person with individual thoughts and goals. This stage is referred to as: intimacy vs. isolation. identity vs. role confusion. industry vs. inferiority. autonomy vs. doubt and shame.
identity vs. role confusion.
