Adolescent 4711
When assessing a 17-year-old client with depression for suicide risk, which question would be best?
"Are you thinking about killing yourself?"
An adolescent with pneumonia shares fears of having contracted human immunodeficiency virus (HIV). The adolescent wants to be tested but does not want parental involvement. What should the nurse say?
"The healthcare provider will run the test confidentially." Federal laws state that adolescents may be tested for sexually transmitted diseases without their parents' permission. The rules of confidentiality apply to this adolescent. The adolescent doesn't have to speak with anyone before the test. HIV can be contracted at any age, even during infancy and childhood. Asking why the client thinks HIV is possible may exhbit therapeutic communication, but it does not address the client's concern.
An adolescent has skeletal traction for a fractured femur. Which is the most appropriate nursing intervention for this client?
Assess pin sites every shift and as needed.
An adolescent girl is prescribed amoxicillin for an ear infection. The nurse should teach the adolescent about the risks associated with her concurrent use of:
oral contraceptives
A nurse is assessing a severely depressed adolescent. Which finding indicates the highest risk of suicide?
a preoccupation with death
A nurse is caring for a 16-year-old male client who needs an appendectomy. His parents are not present at the hospital. Prior to the surgery, the nurse needs to ensure that informed consent is obtained. Which situations allows the healthcare provider to obtain an informed consent from an adolescent?
The adolescent has declared himself emancipated.
An adolescent with insulin-dependent diabetes is being taught the importance of rotating the sites of insulin injections. The nurse should judge that the teaching was successful when the adolescent identifies which complication that can result of using the same site?
destruction of the fat tissue and poor absorption
A nurse is assigned to an adolescent. Which nursing diagnosis is most appropriate for a hospitalized adolescent?
fear related to altered body image
The nurse is instructing a client with cancer who is receiving chemotherapy about reporting signs of infection. Which is the most reliable early indicator of infection in a client who is neutropenic?
fever
A 14-year-old client in skeletal traction for treatment of a fractured femur is expected to be hospitalized for several weeks. When planning care, the nurse should take into account the client's need to achieve what developmental milestone?
identity
An adolescent client who is being seen by the crisis nurse after making several superficial cuts on her wrist states that all her friends are siding with her ex-boyfriend and will not talk to her anymore. She says she knows that the relationship is over, but "If I can't have him, no one else will." Which client problem takes the highest priority?
risk for other-directed violence
Which substance should the nurse include in the teaching plan for a teenager with acne who has requested information about cleansing the affected skin?
soap and water
When assessing a 13-year-old adolescent, what is an expected finding?
subjective judgments of right and wrong
An adolescent becomes increasingly withdrawn, is irritable with family members, and has been getting lower grades in school. After giving away a stereo and some favorite clothes, the adolescent is brought to the community mental health agency for evaluation. Which aspect of the adolescent's behavior is most suggestive of suicide?
suicide plan
What should be the priority assessment for an adolescent on return to the nursing unit after an appendectomy?
the dressing on the surgical site
An overweight adolescent client has lost 12 lb (5.4 kg) in 8 weeks using diet strategies. The client reaches a weight loss plateau and is discouraged. The nurse instructs the client to keep a food diary for what purpose?
to help the client analyze how much food is consumed and when
Which statement by an adolescent receiving gentamicin should the nurse interpret as indicating drug toxicity?
"I'm feeling dizzy."
A new client has just been admitted to an adolescent psychiatric inpatient unit. The charge nurse and an unlicensed assistive personnel (UAP) are discussing the client's needs. The UAP says, "She is just showing off to try and get our sympathy. There is no need for her to cut herself. Why would adolescents want to do such a thing to themselves?" What response by the charge nurse would most help the UAP understand the client and her illness?
"It's hard to see a young person harm herself as she does, but she has serious family issues and doesn't know better ways to handle them, so we have to help her with that."
A 13-year-old girl is being evaluated for possible Crohn's disease. She is about to undergo a colonoscopy with biopsy. While teaching about the diagnosis, the nurse is asked whether the client's delayed puberty is a result of the disease process. Which is the nurse's best response?
"No definitive diagnosis has been made yet; it's best to wait until testing is complete."
The morning blood glucose is 202 mg/dL (11.2 mmol/L) and the client is going to eat 2 carbohydrate exchanges. The nurse has the client administer how many units of lispro? Record your answer using a whole number.
4 Each carbohydrate food exchange has 15 grams of carbohydrate. Two units are needed to cover the current blood glucose, and 2 units are needed to cover the anticipated carbohydrate intake.
An adolescent who is immobilized in a cast to stabilize a recent fractured femur suddenly develops chest pain, dyspnea, diaphoresis, and tachycardia. The nurse should further assess the client for what condition?
pulmonary emboli
A student with type 1 diabetes tells the nurse she is feeling light-headed. The student's blood sugar is 60 mg/dL (3.3 mmol/L). Using the 15-15 rule, what should the nurse do to treat the blood glucose?
Administer 15 g of carbohydrate and retest the blood sugar in 15 minutes.
The nurse is providing nutrition counseling for an obese adolescent. What is the most effective way for the nurse to obtain a nutrition history from this client?
Ask her what she ate yesterday if it was a typical day.
Two months after an adolescent's thoracic spinal cord injury, he has a pounding headache. The nurse notes that the client's arms and face are flushed and he is diaphoretic. What should the nurse do next?
Check the patency of the urinary catheter.
An adolescent is at risk for injury related to intracranial pathology following a motor vehicle collision. Which nursing action is the priority?
Monitor intrancranial pressure.
An adolescent is on the football team and practices in the morning and afternoon before school starts for the year. The temperature on the field has been high. The school nurse has been called to the practice field because the adolescent is now reporting that he has muscle cramps, nausea, and dizziness. Which action should the school nurse do first?
Move the adolescent to a cool environment.
An adolescent client is hospitalized with bacterial meningitis. At 1730, the client's mother reports her child is "burning up." The nurse is reviewing the client's medication administration records in the medical record. The health care provider (HCP) has prescribed ibuprofen 325 mg every 3 to 4 hours for temperature over 99°F (37.2°C). The child's temperature at 1730 is 102.5°F (39.1°C). What should the nurse do first?
Notify the HCP.
A nurse is caring for an adolescent involved in a motor vehicle crash. The adolescent has a chest tube in place. If the chest tube is accidentally removed, the nurse should immediately:
Petroleum gauze
An adolescent client is admitted with a diagnosis of rheumatic fever and is on bed rest. He has a sore throat. His joints are painful and swollen. He has a red rash on his trunk and is experiencing aimless movements of his extremities. Use the chart above to determine what the nurse should do first.
Report the heart rate to the health care provider (HCP).
An adolescent presents to a community clinic for treatment of vulvar lesions associated with Type 2 herpes simplex. Which action does the nurse take?
Show the adolescent to a private examination room for further assessment.
Which instructions about activities during menstruation would the nurse include when counseling an adolescent who has just begun to menstruate?
Take a mild analgesic if needed for menstrual pain.
The nurse is caring for an adolescent client after an overdose on barbiturate drugs and alcohol. The client is hypotensive with a mean arterial pressure below 30 mm Hg and a urine output of 5 mL/hr. Serum creatinine and potassium are elevated. The parents of the client ask why there is so little urine in the indwelling catheter drainage bag. What is the best response by the nurse?
There is not enough blood circulating to the kidneys
A nurse is preparing a health promotion program for teenagers focusing on lifestyle choices. Which of the following methods used by the nurse will best ensure the success of the program?
creating a safe environment for sharing information
The nurse is caring for a 15-year-old adolescent mother after birth. The adolescent lives at home with her parents and has a boyfriend who is also 15 years old. Neither is currently working, and they both have plans for higher education. When addressing the psychosocial issues that may occur after the birth of the child, which of the following would be the most important for the nurse to include in client teaching?
increased stress for new mothers
Which client action should the nurse judge to be a healthy coping behavior for a male adolescent after an appendectomy?
insisting on wearing a T-shirt and gym shorts rather than pajamas
The nurse is assessing a 17-year-old client with a seizure disorder. Driving privileges were suspended for failure to comply with anti-epileptic medications. The parents express concern because the client is withdrawn, not completing schoolwork, and spends increased time sleeping. Which is the nurse's best response?
"Further evaluation is needed for a mood disorder."
The nurse instructs parents about the physical signs to look for in their child suspected of using cocaine. What finding should the nurse tell the parents is consistent with cocaine use?
"His pupils would be large."
Which of the following is a normal response from an adolescent who has just returned to her room after an open appendectomy?
"I am worried about the size of my scar."
A nurse is providing health teaching to a group of adolescent girls. The focus is urinary tract infections . One of the girls tells the nurse that she wants to know what is cystitis. Which statement by the nurse is the most appropriate response?
"This condition can result from irritation and inflammation from sexual activity." Cystitis is a lower urinary tract infection. One cause seen in young adolescent women is after their first sexual intercourse experience. The urinary tract infections occur because of inflammation and local irritation caused by sexual activity. Bladder infections can lead to complications, and, so, are not minor or harmless. A bladder or uretheral infection is not the result of vaginal cleanses such as douches.
A nurse is caring for an adolescent who is in the hospital for a long-term illness. Which of the following interventions would promote the development of the hospitalized adolescent?
Connect the teen to their peer group as much as possible
After an appendectomy, an adolescent is alert and oriented. Parenteral fluids are infusing, and a nasogastric tube is attached to low intermittent suction. Which nursing measure would be most appropriate for the adolescent during this early postoperative period?
Encourage the adolescent to urinate frequently.
An adolescent in the terminal stage of leukemia cries out for more pain medicine. What is the best action for a nurse to take in caring for this dying adolescent?
Give the adolescent more pain medication to control pain and suffering.
An adolescent client has seen the school nurse several times with headache, vomiting, and difficulty walking. When calling the adolescent's mother about these symptoms, the nurse should suggest the mother do what first?
Make an appointment with the adolescent's health care provider (HCP).
A 15-year-old with acute lymphocytic leukemia has been caught hiding her oral chemotherapy each morning. Which nursing intervention will improve compliance?
Have the child meet teenage survivors of cancer who were compliant with treatment.
A 15-year-old adolescent confides in the nurse that the adolescent has been contemplating suicide. The adolescent has developed a specific plan to carry it out and pleads with the nurse not to tell anyone. What is the nurse's best response?
"For your protection, I can't keep this secret. After I notify the physician, we will need to involve your family. We want you to be safe."
A nurse is performing a psychosocial assessment on a 14-year-old adolescent. Which response to the assessment questions is not typical during early adolescence?
"I'm sorry for how I acted earlier. Let's finish these questions."
The parents of a pregnant adolescent are outraged that they are being refused medical information about their daughter's condition. What is the best response by the nurse to address their anger?
"If we obtain permission from her, we can include you in our discussions."
A 16-year-old client is admitted to the emergency department following an accident. The client sustained a head injury, is unconscious, and has compound fractures of the right tibia and fibula. No family members accompanied the client and none can be reached by phone. The surgeon instructs the nurse to take the client to the operating room immediately. Which of the following actions should the nurse take regarding informed consent?
Take the client to the operating room for surgery without informed consent. The surgeon can take responsibility for consent in this situation because the condition is life (and limb) threatening and delaying the surgical treatment would have a negative impact on the client. The other options would delay the life-saving surgery and would result in negative outcomes for the client. The hospital chaplain has no authority to sign a consent form on behalf of the client.
The nurse is caring for an adolescent who has been admitted several times with uncontrolled type 1 diabetes. The child is now stabilized and is preparing for discharge. Which of the following should be the priority focus for the nurse when conducting discharge teaching?
management of the therapeutic regimen
A 15-year-old client with a urinary tract infection is admitted to the facility. The adolescent tells the nurse she hopes she's pregnant. How should the nurse respond?
"Tell me what being pregnant would mean to you."
A nurse has been caring for an adolescent client in a residential facility. The child has been through a series of foster placements since infancy with no success in any placement until the age of 7 when placed with a middle-aged single woman. The client thrived there until the woman was killed in a car accident. The client attempted suicide after her foster mother died in response to the loss and the child was placed in the residential facility. The nurse has become close to this client and wants to help her address her issues and move on with her life. Which comment to the manager demonstrates that the nurse understands the client's issues and is able to respond appropriately to the client's needs?
"It's difficult for her to love and trust again after her losses. In this facility, she can learn to deal with her loss in a less emotionally charged environment than a foster home."
A nurse teaches an adolescent client with asthma to independently administer breathing treatments. Which principle should the nurse keep in mind when planning the teaching session?
Adolescents are worried about appearing different from their peers. Adolescents have a strong need to belong, and they seek social approval from their peers. Knowing this information will help the nurse construct an effective teaching plan. According to Piaget, adolescents are at the formal operations stage and are capable of deductive, reflective, and hypothetical reasoning. According to Erikson's stages of psychosocial development, adolescence is the stage of identity versus role confusion. During this stage, the adolescent strives to establish a sense of identity. There is no reason to think the adolescent will be uncooperative. Many people find video tutorials useful, but a return demonstration is the best way to ensure the client understands and is able to follow the instructions. The nurse can assess the client's abilities without the client requiring supervision at home.
When developing the plan of care for a 14-year-old boy who is bored due to being immobilized in a cast, which activitiy is most appropriate?
playing a card game with a boy the same age
The nurse discovers that an adolescent client with anorexia nervosa is taking diet pills rather than complying with the diet. What should the nurse do first?
Listen to the client discuss fears of losing control of eating while being treated.
The nurse is assessing an adolescent 1 hour after admission for a head injury. The nurse identifies that there have been changes since the baseline assessment, including apnea, bradycardia, and a widening pulse pressure. What is the primary reason for the nurse to notify the healthcare provider?
The changes suggest that the client's intracranial pressure is increasing Cushing's triad (apnea, bradycardia, and widening pulse pressure) is a hallmark of increasing intracranial pressure, which indicates that the adolescent's condition is deteriorating. It is correct that the healthcare provider must be alerted to significant changes and may need to change orders. The client may need additional testing. However, the primary reason to notify the healthcare provider is so the obvious increase in intracranial pressure can be managed using a holistic and emergent approach.
The nurse developed a plan of care for an adolescent who is receiving chemotherapy for lymphoma and has developed stomatitis. What statement made by the adolescent demonstrates understanding of the education provided from the plan of care?
"I will rinse my mouth every 2-4 hours with baking soda and water." White patches on the tongue and oral mucosa indicate oral candidiasis and the adolescent should report the presence of this to their physician but should not attempt to remove them. Using a hard bristle toothbrush can cause trauma to the mucous membranes of the mouth and the client should be instructed to use a soft bristle brush. Rinsing the mouth every 2 to 4 hours with a nonirritating solution, such as baking soda and water or normal saline solution helps prevent stomatitis. The client should avoid commercial mouthwashes with alcohol, which may dry out the mucous membranes.
When developing the teaching plan for an adolescent with insulin-dependent diabetes, the nurse should include what information about the relationship between exercise, diet, and insulin?
"If your blood glucose is 240 mg/dL (13.3 mmol/L) or above, do not run." Strenuous exercise, such as running, should be avoided if the adolescent's blood glucose level is 240 mg/dL (13.3 mmol/L) or above because it places the client at risk for hypoglycemia. When insulin levels are not adequate, the cells cannot receive glucose, even though the blood glucose level is high. With low insulin levels, glucagons act to increase hepatic glucose production, thus raising the blood glucose level, which cannot be used at the muscle site. Taking extra insulin prior to strenuous exercise also increases the risk of hypoglycemia. Vigorous muscle contraction increases local blood flow and absorption of insulin injected into that area. Because exercise decreases blood glucose levels, snacks should be given before strenuous exercise to prevent hypoglycemia. If the adolescent cannot tolerate the extra needed food, insulin dosage may have to be reduced.
