Chapter 36
The school nurse is planning an education program for fourth-grade children regarding prepubescent changes. What nursing action will make the educational program successful? 1. Discussing program content with the parents 2. Talking to all of the classes at one time 3. Planning the program for after school 4. Having the parents present during the program
Answer: 1 Explanation: 1. At this age, the information might be new to the child. Involving the parents might entail a preprogram discussion by the parents with the child, or giving the parents a guide to discuss and reinforce later. If the parents and child are able to communicate about the changes, this will promote communication throughout the rest of the growth of the child. 2. Having boys and girls together for this information might be embarrassing or stressful for this aged child. 3. Some children would be unable to attend after school. 4. The children might not be comfortable having their parents present during the program.
The school nurse is assessing an adolescent who reports getting less than 6 hours of sleep at night. Which consequences of inadequate sleep will the nurse include when responding to the adolescent? Select all that apply. 1. Hyperactivity 2. Increased nocturnal emissions 3. Increased risk of automobile accidents when driving 4. Moodiness 5. An inability to perform well at school
Answer: 3, 4, 5 Explanation: 1. Inadequate sleep is more likely to lead to hypoactivity. 2. This is a common occurrence of early adolescence and not related to sleep deprivation. 3. This is a possibility in the adolescent who is sleep deprived. 4. Parents often report that sleep-deprived adolescents tend to be moody and are difficult to communicate with. 5. Drowsiness will inhibit the performance of the adolescent
Which should the nurse keep in mind when providing care to an adolescent client during the initial visit? 1. The importance of explaining procedures and introducing personnel to adolescents. 2. Adolescents usually are quiet and will offer no opinions. 3. The importance of attending to and discharging the adolescent quickly. 4. Adolescents are comfortable with their surroundings.
Answer: 1 Explanation: 1. If the setting is new to the adolescent, explain the procedures and introduce personnel so the adolescent feels more at ease. 2. Adolescents usually will offer their opinions readily. 3. It is important that adolescents feel welcome, important, and unrushed in order to gain their trust. 4. When adolescents are visiting the same office or clinic that they came to during childhood, they usually know and feel comfortable with the healthcare providers. This is not the case if it is a first visit.
A mother reports that her adolescent daughter is always late. The mother states, "She was born late and has been late every day of her life." Which response by the nurse is appropriate? 1. "Setting specific alarms and then reinforce the value of being 'on-time' may be helpful strategies to assist her to be more of an 'on-time' individual." 2. "Just let it go for now. Teachers and, in the future, employers will be the best people to help her be 'on-time.'" 3. "You need to establish specific time frames for your adolescent and be certain she adheres to them." 4. "You have a major problem. There must be a lot of screaming in your home."
Answer: 1 Explanation: 1. The best response is to help the mother find a way to help the teen deal with the problem of lateness. 2. It is not appropriate for the nurse to advise the mother to do nothing. The parents are the ones responsible for changing their child's behavior. 3. The nurse who tells the mother to establish time frames is making the assumption this is not already the case in the household. 4. This answer choice makes assumptions about the household communication in which the parent and adolescent live.
Which is the most appropriate assessment question for the nurse to ask when collecting nutritional data from an adolescent client? 1. "How do you feel about your weight and the way you look?" 2. "What did you have to eat so far today?" 3. "What is your favorite grocery store?" 4. "Do you eat school lunches or pack a lunch from home each day?"
Answer: 1 Explanation: 1. The best way to obtain information to include in the plan of care is to use a broad opening question. It also is important to ask information about the way the child feels about his or her body image. 2. Asking about eating habits contributes to the nutritional history but is not the most helpful individual aspect in establishing a comprehensive plan of care. 3. Asking about food selection at a grocery store contributes to the nutritional history but is not the most helpful individual aspect in establishing a comprehensive plan of care. 4. Asking about food selection at school contributes to the nutritional history but is not the most helpful individual aspect in establishing a comprehensive plan of care.
A school nurse is performing annual height and weight screening. The nurse notes that three adolescent girls who are close friends each lost 15 pounds over the past year. Which is the priority nursing action? 1. Obtaining a nutritional history for each of these adolescents 2. Referring these adolescents to the school psychologist 3. Calling the respective parents to discuss the eating patterns of each adolescent 4. Speaking with the adolescents in a group to discuss the problems associated with anorexia nervosa
Answer: 1 Explanation: 1. The school nurse must evaluate why these three friends have all lost 15 pounds in 1 year. The best way to begin this assessment is to obtain a nutritional history for each client. 2. Referring the adolescents to a school psychologist without performing a complete nursing assessment is not appropriate. 3. Speaking with the parents would not be appropriate at this time. 4. Discussing anorexia nervosa at this point is too extreme.
The nurse develops and implements a health promotion plan for an adolescent client. What should the nurse include in the evaluation of the plan? 1. Methods to expand and sustain successful approaches 2. Instruction to the client on what is considered healthy behavior 3. Advice for promoting health behaviors that will maintain a healthy lifestyle 4. Information on the client's attitude toward health
Answer: 1 Explanation: 1. When establishing youth programs, whether with individual adolescents or with groups, the nurse includes methods to expand and sustain successful approaches. 2. Instruction on healthy behaviors would be included in the implementation phase of the plan. 3. Advising why promoting healthy behaviors is important is part of the implementation phase of the plan. 4. Including the adolescent's attitude toward health has little to do with evaluating the success of the plan.
Which screenings are appropriate for an adolescent client who admits to being sexually active during a scheduled health maintenance visit? Select all that apply. 1. Herpes simplex virus 2. Gonorrhea 3. Chlamydia 4. Impetigo 5. Mononucleosis
Answer: 1, 2, 3 Explanation: 1. Herpes simplex 1 and 2 can be sexually transmitted and should be included in the screening. 2. Some individuals with gonorrhea may display no symptoms. Because it is a sexually transmitted infection, screening for it would be appropriate. 3. Chlamydia is the most common sexually transmitted infection in the United States. Screening is appropriate. 4. Impetigo is a skin infection caused by staphylococcus or streptococcus; it is not a sexually transmitted infection. 5. Although mononucleosis is sometimes called "the kissing disease," it is not considered a sexually transmitted infection. Sexual intercourse is not required for transmission.
Which will the nurse include in the assessment process for a school-age child who is exhibiting poor school performance? Select all that apply. 1. Hearing screen 2. Muscle tone 3. Dental inspection 4. Vision screen 5. Throat culture
Answer: 1, 2, 4 Explanation: 1. Children with problems with vision, hearing, and muscle tone are at risk for poor school performance because most school activities involve listening, seeing, and kinetic activity. A hearing screen is appropriate for the nurse to include in the assessment process. 2. Children with problems with vision, hearing, and muscle tone are at risk for poor school performance because most school activities involve listening, seeing, and kinetic activity. A muscle tone assessment is appropriate for the nurse to include in the assessment process. 3. School performance would not likely be affected by dental caries. 4. Children with problems with vision, hearing, and muscle tone are at risk for poor school performance because most school activities involve listening, seeing, and kinetic activity. A vision screen is appropriate for the nurse to include in the assessment process. 5. School performance would not likely be affected by chronic tonsillitis.
The nurse is planning care for an adolescent whose parents have both recently been laid off from their jobs. Which is the priority diagnosis for the adolescent and family? 1. Disturbed Sleep Pattern 2. Imbalanced Nutrition: Less Than Body Requirements 3. Knowledge Deficit 4. Risk for Injury
Answer: 2 Explanation: 1. A Disturbed Sleep Pattern may be occurring; however, this is not the priority nursing diagnosis. 2. Imbalanced Nutrition often occurs due to family financial struggles. This is the priority nursing diagnosis for the adolescent. 3. Knowledge Deficit is an appropriate diagnosis as the adolescent and family may require education regarding community resources that will be beneficial at this time; however, this is not the priority nursing diagnosis. 4. Risk for Injury is an appropriate nursing diagnosis for any adolescent client; however, this is not the priority given the current situation.
Which question is appropriate for the nurse to include in the assessment for an adolescent client related to developmental tasks? 1. "How are you adapting to the high school setting?" 2. "What type of relationship do you have with your friends? 3. "Have you thought about your future career goals?" 4. "Do you play any team sports?"
Answer: 2 Explanation: 1. Adapting to high school is not the primary psychosocial developmental task of adolescence. 2. The primary task for the adolescent is to separate from parents and develop positive peer relationships. 3. Adolescents are considering various future occupations, but that is not their primary developmental task. 4. Although this is beneficial, it is not the developmental task of adolescence.
The nurse is planning to teach a group of adolescents about what can happen when having unprotected sex. Which nursing action will allow effective communication with the group? 1. Offering personal opinions on the topic 2. Allowing for discussion among the participants 3. Lecturing on the topic for the allotted time without any discussion 4. Discussing sex education related to religious belief
Answer: 2 Explanation: 1. Personal opinions will not carry much weight with a group of adolescents. 2. Whatever the setting, the nurse partners with the adolescent, the parents, and other persons, such as teachers or school counselors, to plan appropriate goals and related interventions. Appropriate interventions include applying communication skills effective with teens, such as listening to concerns, allowing for discussion, and bringing peers who have had experiences related to the topic being discussed. 3. Lecturing without discussion will not draw in the adolescent to the content. 4. Discussing sex education from a religious viewpoint is not appropriate.
Which nursing action is best when teaching adolescent health promotion and health maintenance topics? 1. Contacting the parents and asking what issues they have with their adolescents 2. Having the adolescents identify a personal health goal 3. Asking the advice of the counselors at school 4. Telling the adolescents information that will be included in the lecture
Answer: 2 Explanation: 1. Talking to the parents first is not necessary. Common issues that arise for adolescents should be discussed in general and not according to specific individuals. 2. Teaching topics will be directed at both health promotion and health maintenance. A good starting point is to have the adolescent identify a personal health goal, and begin teaching there. 3. It is not necessary for the nurse to ask the counselors at school for advice on health topics. 4. Lecturing an adolescent group is not as effective as having an honest and open discussion with adequate time for questions.
The following information is collected during the nursing assessment: the adolescent's menses began when she was 12 years old; a current body mass index (BMI) of 27.5; inconsistent school performance over the last several years. Which is the priority area of teaching for this adolescent? 1. Menstrual cycle 2. Nutritional intake 3. School performance 4. Mental health status
Answer: 2 Explanation: 1. The menstrual cycle appears to have started at a normal time, and so it is not the priority. 2. The BMI for this client is too high, placing the adolescent at risk for cardiovascular disease, hypertension, and diabetes mellitus in later life. Therefore, nutritional intake is the most important topic to focus on with this client at this time. 3. School performance is important; however, this is not the priority. 4. Mental health status is important; however, this is not the priority.
The nurse is assessing an adolescent patient during a scheduled health maintenance visit. The adolescent's mother is currently in the examination room with the patient. Which topic should the nurse avoid until the mother has left the examination room? 1. School performance 2. Cigarette smoking 3. School friends 4. Seat belt use
Answer: 2 Explanation: 1. The nurse can ask general questions about seat belt use, academic performance, and school friends without breaching confidentiality. 2. The nurse must maintain the nurse-client relationship, which is between the nurse and the adolescent, and the nurse must maintain confidentiality. Therefore, the nurse cannot ask any personal questions while the mother is in the room, such as those related to sexual activity, drug and alcohol use, and smoking cigarettes. 3. The nurse can ask general questions about seat belt use, academic performance, and school friends without breaching confidentiality.
The nurse is assessing an adolescent client to determine relationships with others. Which nursing action is appropriate? 1. Telling the parents that information from the assessment will be shared with them after the examination 2. Providing separate time to communicate with both the adolescent and the parents 3. Avoiding asking the parents their opinions of the adolescent's friends 4. Telling the parents they are not allowed to come into the examination room
Answer: 2 Explanation: 1. The nurse cannot share the information about the examination, as this is a breach of client confidentiality. 2. Provide time alone with both the adolescent and the parents so that everyone has time to talk freely and ask questions. 3. The nurse should include the parents' opinions of their child's friends. 4. The nurse cannot keep the parents out of the examination room, especially if the adolescent wants the parents there.
During a health maintenance visit an adolescent states, "I have no friends in my new school, and I no longer want to go to college. I know I will be lonely there, too." Which is the priority nursing action? 1. Stressing the importance of remaining in a close parent-child relationship during these stressful times 2. Promoting healthy mental health outcomes 3. Acknowledging the fact that it takes several months to make new friends at a new school due to adolescent exclusion behaviors 4. Helping the adolescent realize the value of postsecondary education
Answer: 2 Explanation: 1. The parent-child relationship should not be used as a substitute for the development of new peer relationships. 2. The adolescent is obviously lonely with the move to the new school. The nurse should focus on appropriate coping skills, which will enhance good mental health outcomes for the child. 3. It would be more upsetting to the adolescent if the nurse made this comment. 4. It would not be appropriate to discuss the importance of a college education at this time because the adolescent must deal with the loss of friends and with developing new friends first.
The nurse notes dental issues during the assessment of an adolescent client. Which topics will the nurse explore further to determine the cause of the issues? Select all that apply. 1. Use of fluoridated water 2. Use of a mouth guard when playing physical sports 3. Anorexia nervosa 4. Bulimia nervosa 5. Use of daily vitamins
Answer: 2, 3, 4, 5 Explanation: 1. Fluoride is not needed in the adolescent once all teeth have emerged; this does not constitute a risk factor. 2. Sports injuries can be the cause of dental issues without proper safety equipment, such as a mouth guard. 3. Dental injuries can be related to eating disorders. 4. Repeated vomiting can destroy enamel due to contact with acidic stomach juices. 5. A lack of certain vitamins can cause dental issues.
Which teaching topics are appropriate for the nurse to include for an adolescent who admits to the use of chewing tobacco? Select all that apply. 1. Lung cancer 2. Nicotine addiction 3. Mouth cancers 4. Emphysema 5. Mouth ulcers
Answer: 2, 3, 5 Explanation: 1. Smokeless tobacco does not increase the risk of lung cancer. 2. Nicotine addiction occurs with chewing tobacco just as it does with smoking cigarettes. 3. Cancer of the mouth is associated with chewing tobacco. 4. Respiratory illnesses are not a common risk factor for smokeless tobacco. 5. Mouth ulcers occur in individuals who chew tobacco.
An obese adolescent who adamantly denies sexual activity has a positive pregnancy test. Which response by the nurse is most appropriate? 1. "When was your last menstrual period (LMP)?" 2. "Tell me how you feel about your body image." 3. "Let's discuss some activities that you have done within the past few months that could possibly lead to pregnancy." 4. "Why are you denying sexual intercourse?"
Answer: 3 Explanation: 1. Asking about the LMP does not help connect the adolescent's past behavior to her pregnancy. 2. The adolescent's body image does not address the teen's current situation. 3. The nurse must help the adolescent realize that previous behaviors have led to a positive pregnancy test. The only response by the nurse that will accomplish this goal is to ask a direct question in which the nurse and client search for an answer. 4. This option is too confrontational and may alienate the adolescent.
A nurse obtains a nutritional health history from a 10-year-old child. Which food increases the risk for dental caries necessitating education regarding oral hygiene? 1. Sorbet and yogurt 2. Fluoridated water 3. Gummy bears and licorice 4. Peanuts and crackers
Answer: 3 Explanation: 1. Foods such as peanut butter, crackers, sorbet, and yogurt do not stick to the teeth, and are not considered foods that increase dental caries. 2. Fluoridated water has been shown to decrease the incidence of dental caries. 3. Food items that stick to the teeth lead to dental caries. Items such as gummy bears and licorice stick to the teeth and lead to dental caries. 4. Foods such as peanut butter, crackers, sorbet, and yogurt do not stick to the teeth, and are not considered foods that increase dental caries.
Which nursing action is appropriate when providing care to an adolescent client who is accompanied to an appointment by a parent? 1. Instructing the parent to stay in the waiting room with the explanation that the adolescent will provide a report after the examination 2. Telling the parent it is against policy for a parent to accompany the adolescent to the examination room 3. Reassuring the parent that the nurse will discuss any parental concerns or questions after the examination 4. Allowing the parent to come into the examination room with the adolescent
Answer: 3 Explanation: 1. The adolescent makes the decision about the parent's presence and whether to report the examination to the parent. 2. The adolescent decides when the parent comes into the room. 3. If one or both parents come with the adolescent, be alert that you might need to provide some private time by asking the parents to wait outside for a moment. Reassure the parents that you will talk with them about any of their concerns and questions, and provide them with an opportunity to ask questions and get information as well. 4. The adolescent chooses when the parent comes into the room.
The nurse is assessing an adolescent client during a scheduled health maintenance appointment. Which issues should the nurse address when the parents are not present? 1. The adolescent's role in the family 2. Teen job responsibilities 3. Possible domestic violence 4. Activities done as a family
Answer: 3 Explanation: 1. The adolescent's role in the family is not confidential and could be discussed when the parents are present. 2. Job responsibilities are not confidential and could be discussed in front of the parents. 3. If domestic violence is suspected, it would be appropriate to ask these questions only when the teenager is alone with the nurse or healthcare provider. 4. The activities of the family are not confidential and could be discussed when the parents are present.
An overweight school-age girl states, "I would like to be more active but my parents won't let me try out for the soccer team." Which is an appropriate nursing action based on this statement? 1. Referring the child to the school psychologist to discuss the weight issue 2. Telling the child to talk to the school nurse each day about the foods eaten 3. Encouraging the parents to investigate the option of ride sharing with a classmate's family 4. Suggesting that the family plan an activity night and play board games together
Answer: 3 Explanation: 1. This child has interest in, but a lack of opportunity for, physical activity. She has not indicated that she has an eating disorder or mental health issue. 2. Telling the nurse all the food she eats each day is monitoring, and she might feel more self-conscious and different from her peers if this is a daily event. 3. Sharing rides with another family might allow the girl to get involved with a physical activity after school and still have the parents involved. 4. Planning a family activity is a beginning step, but not board games; something active to increase physical activity would be better.
During the psychosocial portion of the nursing assessment a school-age child states, "I know I am not as good as them, so I just play by myself at recess every day." Which conclusion by the nurse is accurate? 1. The child has a good sense of self-worth. 2. The child has a poor body image. 3. The child has decreased self-esteem. 4. The child has a self-determined concept.
Answer: 3 Explanation: 1. This child would not have a good sense of self-worth. 2. There are no data in this scenario to indicate that the child has a problem with body image, since there is no information related to why other children are teasing the child. 3. The child's statement reveals no interaction with other children during play periods; therefore, the child's self-esteem is low. 4. There are no data in this scenario to indicate whether the child has a self-determined concept.
) Which nursing action maintains confidentiality when performing height and weight measurements during a co-ed physical education class? 1. Having a student worker record the screening findings on the appropriate adolescent's record 2. Having a volunteer weigh and measure the adolescents and verbally give the findings to the nurse to calculate the body mass index and record 3. Providing a privacy screen and have the health aid record the findings directly on the record. The nurse will then calculate body mass index 4. Using a buddy system with the students, having the students measure each other and record the findings.
Answer: 3 Explanation: 1. This would be inappropriate. Other students should not have access to any adolescent's private information. 2. Volunteers should not be included in the process of gathering data. Verbal reporting of findings would allow other adolescents to hear the results, violating the confidentiality of the student being screened. 3. A privacy screen and written responses will prevent other adolescents for hearing or seeing results. 4. Although this limits the number of adolescents who have access to personal data, this still is an invasion of privacy.
Which screening is appropriate for the school nurse to perform on all adolescent students? 1. Respiratory rate 2. Hepatitis B profile 3. Chest x-ray 4. Scoliosis
Answer: 4 Explanation: 1. A respiratory rate is not a screening examination for all adolescents. It is done throughout childhood at each health supervision visit. 2. The hepatitis B profile is needed only once, prior to administration of the hepatitis B vaccine; however, this is not a required screening for all adolescents. 3. A chest x-ray is not a routine screening test for adolescents. 4. Routine screening for adolescents includes checking for scoliosis, height, weight, and blood pressure measurements.
The mother of a 12-year-old child informs the nurse that the child's father died from sudden cardiac death at 44 years old. Which laboratory tests does the nurse anticipate will be prescribed by the healthcare provider? 1. Chest x-ray 2. Complete blood count (CBC) with differential 3. Electroencephalogram (EEG) 4. Lipid profile
Answer: 4 Explanation: 1. A routine chest x-ray might be ordered by the healthcare provider, but will not provide relevant information at this time. 2. The CBC is routine, but will not give information related to cardiac disease. 3. An EEG reveals information about brain activity, not about cardiac status. 4. This child should have a lipid profile completed at 12 years old, and based on the results, further testing might be needed.
The nurse is planning care for an overweight adolescent. Which topic may also be appropriate for the nurse to include in the adolescent's plan of care? 1. Substance abuse 2. School phobia 3. Spiritual distress 4. Negative self-esteem
Answer: 4 Explanation: 1. This is not the major mental health issue associated with obesity. 2. While the adolescent may dislike attending school, this is not the mental health problem the nurse should be evaluating. 3. Adolescents may have issues related to spirituality, but this is not associated with obesity. 4. Self-esteem is tied closely to body image, a common source of distress among obese adolescents. Therefore, the nurse will monitor the adolescent for issues with self-esteem
