Chapter 29: Growth and Development of the Adolescent

A black adolescent male has been diagnosed with hypertension. Which statement made by the adolescent indicates to the nurse that additional teaching is needed?

"Drinking sodas is not related to my blood pressure." Rationale: Hypertension is present if the blood pressure is above the 95th percentile, or 127/81 mm Hg for 16-year-old girls and 131/81 mm Hg for 16-year-old boys for two consecutive readings. Adolescents who are obese, who are black, who eat a diet high in salt, or who have a family history of hypertension are most susceptible to developing the condition. Drinking soda regularly increases the amount of sodium intake daily, thus having an impact on the blood pressure.

A male nurse is meeting with a group of 12-year-old boys to discuss expected bodily changes. After one of the boy's says, "My older brother told me my bed might be wet and that means I had a wet dream. Is that true?" What is the best response from the nurse?

"Having wet dreams indicates that your body is going through a process of maturing." Rationale: In boys, the appearance of nocturnal emissions ("wet dreams") is often used as the indication that the preadolescent period has ended and that the adolescent is maturing into an adult. Nocturnal emissions usually occur at about the age of 11 in boys. Wet dreams are not associated with urination. Boys at this age start thinking of relationships with people they find sexually attractive, but this is not the best response.

The nurse is planning a presentation to an adolescent group. What recommendations would the nurse include in the presentation?

Participate in 60 minutes of moderate to vigorous physical activity each day. Rationale: The U.S. Department of Health and Human Services and the Canadian Physical Activity Guidelines recommend that adolescents participate in 60 minutes of moderate to vigorous physical activity each day. Aerobic exercise for 30 minutes, three times weekly, is not the recommended amount of exercise. The other recommendations lack adequate activity or specificity.

The school nurse is developing a school wellness program to promote healthy eating habits and regular physical activity. What is the most important element to emphasize to maximize compliance, healthy habits, and long-term change?

Include both parents and children in the wellness program. Rationale: Every campaign to support good nutrition and daily physical activity must include parents and their children as active members of the learning community. Although the other actions can accomplish in-school enhancements to health, long-term change tends to be more likely when the programs implemented involve the family. Programs implemented without a family-centered approach often fail when the child's home life and school life are disconnected.

The nurse is talking to a 13-year-old boy about choosing friends. Which function do peer groups provide that can have a negative result?

following role models Rationale: Peers serve as role models for social behaviors, so their impact on an adolescent can be negative if the group is using drugs, or the group leader is in trouble. Sharing problems with peers helps the adolescent work through conflicts with parents. The desire to be part of the group teaches the child to negotiate differences and develop loyalties and stability.

Nurses should provide anticipatory guidance to males to prepare them for what particular pubertal change in middle-to-late adolescence?

nocturnal emissions Rationale: Involuntary ejaculation during the night can be disturbing to the adolescent male who has little or no understanding of what is happening in the body. Lengthening of the penis begins to occur in early adolescence as does reddening of the scrotum and emergence of pubic hair.

The nurse is collecting data from a 15-year-old boy who is being seen at the ambulatory care clinic for immunizations. During the initial assessment, he voices concerns about being shorter than his peers. What response by the nurse is indicated?

"Boys your age will often continue growing for a few more years." Rationale: Teenage boys can experience growth in height until age 18 or even later. The nurse should reassure the teen that this may happen for him. Telling the client not to be ashamed or assuring him that he's not as short as his peers fails to provide information or support. Determining the height of the other men in the family may be indicated at a later time but is not the most appropriate initial comment.

The nurse is preparing a presentation for a local health fair depicting the differences in maturity between preadolescents. Which differing factor should the nurse prioritize in the presentation?

Boys grow at a slower, steadier rate than do girls. Rationale: Preadolescent boys grow generally at a slower, steadier rate than do girls. Girls grow more rapidly during preadolescence and then their growth rate slows dramatically after menarche.

The mother of a 9-year-old female voices concern to the nurse about her daughter developing breasts "at such a young age." How should the nurse respond?

"I understand your concern, but girls typically enter puberty around the age of 9 or 10." Rationale: Voicing empathy regarding the mother's concern conveys support, and letting her know that this is normal growth and development helps ease her concerns. The other responses don't address her concerns or show genuine empathy.

The nurse is discussing an adolescent's development with the client's parents. Which statement by the parents indicate an understanding of the nurse's teaching?

"Our adolescent is working toward achieving a sense of personal identity." Rationale: According to Erikson's theory of psychosocial development, the major challenge of adolescence is the achievement of identity. Achieving independence from parental domination is another task of adolescence, but not the ultimate one. Helping other adolescents achieve higher goals is not a part of Erikson's theory of psychosocial development. Developing trust occurs in infancy.

An adolescent's parent states not knowing what to do with the adolescent. The parent reports the teenager is taking two or three showers a day when not that long ago the parent could barely get the teen to take a shower at all. What should the nurse's reply be to the parent?

"Reinforce the family rules but also allow the adolescent to develop one's own routine." Rationale: Adolescents find that frequent baths and deodorants are important due to the apocrine sweat gland secretion activity. The increases in sex hormones and steroids cause the skin to be oily. This leads to more showers or baths daily. This is a time when the adolescent is defining what type of personal hygiene products are preferred. Hygiene and personal care can become a source of family arguments as the young person develops a style of personal care. Parents need to be mindful of the adolescent yet maintain family rules and boundaries regarding aspects of personal care. It is important for teenagers to feel that they have some ability to develop their own personal care standards and daily patterns.

An adolescent who is depressed states, "Nothing ever seems to be right in my life." Which would be the most appropriate response by the nurse?

"You are feeling sad right now. It's a hard time." Rationale: Some degree of depression is present in most adolescents because they are not only losing their parents while they grow apart from them but also their carefree childhood. When using therapeutic communication, it is important for the nurse to accept the client's verbalization as real. Support should be real. Telling the adolescent that things will be better in college provides false reassurance. Telling the adolescent to "look on the bright side of things" or that "being a teen is hard work" offer platitudes and interrupt the client's interactions.

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?

"You seem concerned. Let's talk about your feelings." Rationale: Body image is closely related to self-esteem. Seeing one's body as attractive and functional contributes to a positive sense of self-esteem. During adolescence, the desire not to be different can extend to feelings about one's body and can cause adolescents to feel that their bodies are inadequate even though they are actually healthy and attractive. The nurse would acknowledge the client's concern and discuss the client's feelings. Stating the client is beautiful as is does not address the client's concern. Closed statements which require no response do not offer any insight for the nurse. The nurse would also avoid yes/no questions.

A 17-year-old female is meeting with the nurse for an annual well-visit and is asking the nurse questions about how to know when one is in love. The nurse should point out which factor to help decide if both individuals have reached a mutual agreement and are ready for an intimate relationship?

A sense of trust and identity Rationale: In order to be intimate or to share one's deepest feelings with another person, it is impossible unless both persons have established a sense of trust and a sense of identity. Being autonomous or taking initiative are not aspects that lead toward intimate relationships. Socialization and isolation are not relevant to the establishment of intimate relationships.

Which nursing action will best assist a 15-year-old client accomplish the developmental task according to Erikson?

Allow the client's friends to visit while the client is hospitalized Rationale: The developmental task of adolescence is to develop a sense of identity, or deciding who and what kind of person one is. Friends and peers are important to facilitating the adolescent in determining one's identity. Permitting the client to make decisions assists in developing autonomy, which is a toddler task. Praising facilitates initiative, which is a preschool task. Independently performing tasks assists in developing industry, which is a school-age task.

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. Rationale: The most important aspect of discussions about sexuality with adolescents is giving honest, straightforward answers in an atmosphere of caring concern. Children whose need for information is not met through family, school, or community programs will get the information—often inaccurately—from peers, movies, television, or other media.

To help prevent obesity, which intervention would the nurse include in an adolescent's plan of care?

Describe a normal serving size. Rationale: Some adolescents may be unaware that their food intake is excessive because they have been told they need excess nutrients for healthy adolescent growth and everyone in their family eats large portions. Health teaching with these adolescents may need to begin with a discussion of "normal" weight and standard food portions. If adolescents eat a diet too low in protein for any length of time, they can develop a negative nitrogen balance, which can lead to impaired growth. Therefore, a diet of fewer than 1,400 to 1,600 calories a day can rarely be tolerated by adolescents. Teenage girls who are moderately active require about 2,000 calories per day and teenage boys who are moderately active require between 2,200 and 2,800 calories per day. Eating in excess can lead to obesity and should be avoided.

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?

Formal operational thought Rationale: The final stage of cognitive development, the stage of formal operational thought, begins at age 12 or 13 years and grows in depth over the adolescent years, though it may not be complete until about age 25. This step involves the ability to think in abstract terms and use the scientific method (deductive reasoning) to arrive at conclusions. With the ability to use scientific reasoning, adolescents can plan their future. They can create a hypothesis (What if I go to college? What if I do not?) and think through the probable consequences (In the long run, I will earn more money; I could begin earning money immediately). This scenario does not pertain to socialization, role identification, or sensorimotor development.

The nurse is talking with parents of a depressed 16-year-old boy. Which question is of the most importance?

Is there a gun in your home? Rationale: He may be at risk for suicide. Firearm-related suicides have been responsible for a large number of the suicide deaths in 15- to 19-year-olds nationwide. All the other questions assess for depression and do not protect against suicide.

What anticipatory guidance can the nurse provide the girl who has noted the development of breast buds?

Menarche should follow in about 2 years. Rationale: Menarche usually follows within 2 years of the first signs of breast development. Peak height velocity (PVH) in girls occurs 6 to 12 months following menarche. It does not follow immediately. Breast development progresses through several stages and will not be complete until late puberty. Adult height is not reached at the time of menarche but about 6 to 12 months following menarche.

The nurse is preparing to participate in a community discussion on the needs of the adolescents in the local school. The nurse should point out which goal is the primary concern for these young individuals as the committee makes plans?

Teens are busy developing their own personal identity. Rationale: According to Erikson, the central task of adolescence is to develop unique personality and identity. The developmental task for the school-age child is to develop a sense of industry, and completing activities builds that feeling of confidence. Erikson's psychosocial developmental task for toddlers is to achieve autonomy (independence) and do things on their own. Learning to speak and to understand and respond to discipline are not developmental tasks, according to Erikson.

The nurse is educating a 17-year-old adolescent after a new diagnosis of diabetes. What does the nurse understand about teaching an adolescent?

The adolescent will likely have the greatest influence on one's own decisions. Rationale: In late adolescence, the client likely has the greatest influence on his or her own decision making. While offering teaching to the parents and healthy cooking classes to the siblings are options, the adolescent will most benefit from being the one to make choices about care. Focusing on more recent concerns rather than the idea of future complications with the adolescent will gain more credibility.

The nurse is caring for an adolescent athlete who is being seen for a fractured arm. The parent reports that this is the third sports injury in the past 2 years. The parent asks the nurse why the adolescent—who is healthy overall— continues to have injuries. How should the nurse respond?

The bones, joints, and tendons of adolescents are vulnerable to injury due to their rapid state of growth. Rationale: Rapidly growing bones, muscles, joints, and tendons are more vulnerable to unusual strains and fractures. While some people may seem to be accident-prone, this adolescent's injuries are most likely the result of the stage of physical growth. There is no evidence the adolescent has any underlying medical conditions.

A 15-year-old adolescent is seen at a health care facility for facial acne. When counseling the teen, the nurse would teach that the basic cause of acne is:

activation of androgen hormones. Rationale: Acne occurs in adolescence as the result of hormone influence. With increased androgen production the sebaceous glands become more active. With increased testosterone production (in both boys and girls) increased sebum is produced. These increased hormone productions lead to the development of acne. Showering will certainly lead to cleaner skin and the removal of oils but the lack of showering does not cause acne. Diet and thyroid hormones do not play a role in the development of acne.

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?

motor vehicle crashes Rationale: Although drowning, violence, and suicide are causes of adolescent injury, the largest number of adolescent injuries are due to motor vehicle crashes.

Which behavior by an 18-year-old is consistent with successful progression through the stages of Piaget's theory of development?

uses critical thought processes to handle a problem Rationale: Piaget's developmental theories focus on the cognitive maturation of the child. The ability to critically think is a sign of successful cognitive maturation. A sense of internal identity is consistent with Erikson's theories of development. Kohlberg's theories development focus on morals and values.

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?

"Be sure to clean the navel several times a day." Rationale: The best response is to describe the proper care using frequent cleansing with antibacterial soap. It is too late for warnings about the dangers of piercing such as skin- or blood-borne infections, or disease from unclean needles.

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." Rationale: The average number of hours of sleep that teens require per night is 8.5 to 9.5 due to rapid growth that occurs during these years. Following a curfew and limiting distractions at bedtime can help provide the student with adequate hours of sleep each night.

The mother of a 13-year-old boy confides to the pediatric nurse practitioner that her son has recently had a nocturnal seminal emission. The mother is concerned, and the nurse explains "wet dreams" and the other male traits of puberty to the mother. Which response indicates a need for further discussion?

"My son must be sexually active or having overly sexual thoughts to have a nocturnal emission." Rationale: Spontaneous erections and nocturnal seminal emissions do not mean that the child is sexually active or having overactive sexual thoughts. Parents need to be instructed that these occurrences are spontaneous and that the child is not doing anything to cause them.

A client has confided in a nurse that her 13-year-old daughter has recently changed dramatically in her social interactions with others. What is a social behavior most likely to be exhibited by a girl at this age?

Banding together with other girls and dressing like them Rationale: In early adolescence, girls tend to band together with girls. They dress identically with other members of their group: jeans and sweatshirts, special jackets, or whatever the fashion may be. On the surface, this makes adolescents appear to be losing their identities rather than finding them.

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. Rationale: The highest priority areas of the nurse's teaching involves informing the client about the expected pubertal changes that take place in the body and convincing him that the involuntary discharge of semen while sleeping is a normal part of reproductive health. Once the adolescent has an understanding of bodily changes during puberty then further education about sex, sexuality and sexually transmitted infections can be discussed.

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 and interact with other teens. Rationale: Adolescents need access to their peers so they can keep up social contacts. Meeting other teens in the facility is one way to accomplish that. The client most likely also has an electronic device which will enable her to stay in contact with family and friends back home but meeting others can also help meet social needs. Recreation areas are important. In settings specifically designed for adolescents, recreation rooms can provide an area where teens can gather to do schoolwork, play games and cards, and socialize. Because she is 100 miles from home, a visit from friends might be difficult.

The nurse is providing anticipatory guidance to the parents of a 15-year-old who voice concerns with their teenager's sleep habits. They state, "Left to her own devices, I'm sure she'd stay up until 3:00 in the morning on the weekends and sleep until after lunchtime." Which should the nurse explain to the parents?

"That must be hard for you to manage. Perhaps we can explore some strategies with her to establish more predictable sleep patterns." Rationale: It is common for adolescents to adopt habits of going to bed late and awakening late, especially on weekends. Despite the fact that this is common, it is not ideal; the nurse should explore strategies for changing the adolescent's behavior in a collaborative and inclusive manner. Simply communicating that it is unacceptable is unlikely to bring about change.

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?

"This is common for this age group and it will get better with time." Rationale: During middle adolescence, the adolescent spends more time ignoring adult authority and becomes more reliant on peer relationships. Adolescents might choose a stance directly opposite that of their parents and use peer support to back their ideas. Mood swings are a common occurrence during the adolescent period. They tend to smooth out and the adolescent will become more introspective. By late adolescence emotions become more consistent. Making statements such as "my adolescent will never find anyone to live with" or "we will have to learn to live with [my adolescent's temperament]" does not demonstrate the parent has a good idea of what is happening during the adolescent period.

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?

Allow the adolescent to choose the time for the dressing change. Rationale: Achieving a sense of identity may be difficult for adolescents who have a chronic illness. Some of the nursing actions which encourage identity in the chronically ill adolescent include the following: respecting food preferences; allowing the adolescent to choose the time for the dressing changes; teaching the name, actions, and possible side effects of medication; and respecting modesty. The school can provide homework so the adolescent does not get further behind in school work, and the teen can go to the teen room each day. These provide a good emotional outlet, but they do not promote independence. Teaching the parents to do the dressing changes makes the adolescent dependent on the parents. If the dressings are at a location the adolescent can reach and dexterity is not limited, then the adolescent should be allowed self-care.

A 15-year-old girl is in the hospital for surgery and is confined to bed. The nurse can tell that the client is nervous about being in the hospital. She tells the nurse that she feels "gross" and "on display" in her hospital gown. What should the nurse do to encourage a sense of autonomy and dignity related to the girl's body image?

Offer to assist the girl in washing her hair and let her pick the shampoo. Rationale: When caring for hospitalized adolescents, providing time for self-care, such as shampooing hair, is important to include in an adolescent's nursing care plan. Offering to assist the client in washing her hair and letting her pick the shampoo both encourages a sense of autonomy to the client and offers her dignity related to her body image. Brushing the girl's hair for her and assisting her with using the bed pan for urination do not encourage a sense of autonomy. If it is the hospital's policy to require clients to be dressed in a hospital gown while admitted, the nurse should not allow the girl to wear her own clothes.

While caring for a 16-year-old client expected to be hospitalized for several months, the nurse will perform which action to assist the client in meeting the current stage of psychosocial development?

Permit peers to visit during open visitation hours. Rationale: In each stage of development, a significant person or group exerts a lasting influence on the ongoing development of the child. An adolescent striving for self-identity and increased independence spends more time with peers than with family. It is important for the hospitalized adolescent to still be able to visit with peers. Video games may be enjoyed by the adolescent and limit boredom; however, this action would not facilitate psychosocial development. Allowing the client to touch equipment and to explain medical concepts/procedures are methods used to teach toddlers and preschoolers. Providing handouts and brochures are not effective methods to explain medical concepts; the nurse would verbally explain using models, pictures, and diagrams. Handouts and brochures can be used as supplements to teaching.

What activity would best foster the developmental task of an adolescent who uses a wheelchair to ambulate?

Talking to another adolescent who has a similar situation Rationale: A sense of identity is developed by "trying on" roles and discussing values and goals with others. A sense of trust develops when an adolescent is able to find out whom (and what ideas) to have faith in. The adolescent period is also a time where past stages of development are revisited. The sense of autonomy is where the adolescent seeks ways to express individuality. The stage of initiative is where the adolescent develops vision of what he or she might become. Talking with another adolescent who also uses a wheelchair to ambulate will help the adolescent see possibilities and reassurances. Making decisions or having assistance from someone else does not allow the adolescent to "try out" roles.

A teenage boy tells the nurse that his parents embarrass him in front of his friends when they kiss him goodbye. The nurse is aware that this teenager is revisiting which stage of development identified by Erikson?

autonomy Rationale: In revisiting the stage of autonomy, the adolescent is seeking out ways to express his or her individuality in an effective manner. The adolescent would avoid behaviors that would "shame" or ridicule him or her in front of peers. The sense of industry is again encountered as the adolescent makes the choice to participate in different activities at school, in the community, at church, and in the workforce. Initiative is revisited as the adolescent develops a vision for what he or she might become. Generativity largely involves establishment of career and work.

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." > "My favorite time of day to be outside is the middle of the day, around noon." > "The more exposure and burns I get now will toughen my skin so I won't get skin cancer when I'm older." Rationale: The nurse should further discuss comments that demonstrate incorrect information about sun exposure. Any exposure to tanning beds should be avoided to prevent skin cancer risks. Other risks for skin cancer include being in the sun between the times of 10:00 am and 4:00 pm, and sun exposure and burns during childhood and adolescence. A minimum SPF of 15 should be used, so SPF 30 is good practice, as is wearing sun-protective clothing when outside during the day.

The adolescent comes to the clinic seeking information about sexuality concerns. The clinic nurse assures the adolescent that confidentiality and privacy will be maintained unless a life-threatening situation occurs. Maintaining confidentiality demonstrates which nursing goal? Select all that apply.

> development of a trusting relationship > compliance with existing laws > an environment where adolescents can be truthful Rationale: Adolescents may seek a health care appointment for an unrelated health concern as a reason to discuss a sexual health question with a health care professional. Reassurance should be given to the adolescent that all questions and concerns will be addressed and will be kept confidential. This is the basis for the nurse-client relationship. All questions and concerns do not involve treatment and therefore do not involve parental consent. Parents may voice concerns because they are responsible for the insurance and billing. The nurse should act as a client advocate and work with the parents to develop a mutual understanding of the situation.

An adolescent with a new piercing comes to the health center at the school. The client reports feeling hot. Which action will the nurse complete first?

Assess the client for signs of infection. Rationale: The nurse will first assess the client for signs of infection. The client reports feeling hot, which could indicate a fever. The nurse would assess the client's temperature and for other signs and symptoms of infection, such as redness, swelling, warmness, drainage, discomfort. The nurse would ask when the client started feeling hot and about the technique used for the piercing to gain additional history and insight. However, these questions are not priority over assessing the client. Determining if the client has any additional piercings is not necessary, as this will not provide information about the client's current situation.

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 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. Rationale: When identity has been established, generally between the ages of 16 and 18 years, adolescents seek intimate relationships, usually with members of the opposite sex. Intimacy, which is mutual sharing of one's deepest feelings with another person, is impossible unless both persons have established a sense of trust and a sense of identity. Intimate relationships are a preparation for long-term relationships, and people who fail to achieve intimacy may develop feelings of isolation and experience chronic difficulty in communicating with others.