Peds-Adolescents
Penicillin G (Bicillin) and probenecid (Benemid) are prescribed for an adolescent who has syphilis. The adolescent asks the nurse why two medicines are needed. What should the nurse explain about the rationale for this combination therapy?
"Probenecid delays excretion of penicillin so the blood level of penicillin stays stable longer." Rationale: Administration of probenecid (Benemid) results in better utilization of the penicillin G (Bicillin) because it delays penicillin's excretion by the kidneys. Probenecid is not prescribed to treat urethritis or to prevent allergic reactions. Penicillin destroys Treponema during all stages of its development; the probenecid does not attack the organism during a stage of multiplication.
An adolescent is admitted with an acute hemophilia episode. Rest, ice, compression, and elevation will be most helpful in:
Controlling bleeding and retaining joint function Rationale: Rest, ice, compression, and elevation (RICE) therapy is implemented to support joints and prevent bleeding into joints. Total immobilization is not required. Pain may be relieved to some degree but is not assured. Reducing inflammation is not the goal of treatment for the hemophiliac process.
A nurse on the adolescent unit is planning to discuss smoking prevention. What is the most effective approach for the nurse to use?
Presenting information on how smoking affects appearance and odor of the breath Rationale: Establishing an identity is the major developmental task of the adolescent; to achieve this task, the adolescent needs to conform to group norms that include appearance and acceptance. Appealing to this need may achieve more success than other teaching strategies. Sharing personal experiences with a smoking-cessation program is a teaching strategy that may be successful with an older, more secure group of people. Adolescents tend to believe that they are invincible and probably will not relate to this teaching strategy. They are also concerned about the present, not the future. Because adolescents believe they are invincible, they would not relate to a teaching strategy based on statistics about the harmful effects of smoking.
After an above-the-knee amputation for bone cancer, an adolescent boy is returned to his room. He is monitored closely because of the potential for hemorrhage from the residual limb. What should the nurse plan to keep at the bedside?
Pressure Dressing. Rationale: A pressure dressing will control hemorrhage until surgical intervention can be instituted. A hemostat is not practical because bleeding may be internal. Vitamin K is the antidote for warfarin (Coumadin). There is no indication that the client is taking Coumadin. Protamine sulfate is the antidote for an excessive amount of heparin; the client is not receiving heparin.
A 14-year-old adolescent with diabetes has been self-administering insulin twice a day.. This morning the parents found their child lethargic and confused. After the adolescent's admission to the emergency department, laboratory testing reveals a hemoglobin A1c level of 10% and a blood glucose level of 200 mg/dL. What does the nurse suspect as the most likely cause of this client's condition?
Uncontrolled blood glucose level Rationale: The blood glucose is increased above the expected range of 90 to 130 (5 to 7.2 mmol/L) in adolescents older than 12 years of age, per the American Diabetes Association. Hemoglobin A1c is increased above the expected range of <7.5% in adolescents older than 12 years, per the American Diabetes Association. Although compliance is not optimal in the adolescent population, there are not enough data to justify this conclusion at this time. The Somogyi effect (rebound hyperglycemia) occurs when there is an increase in blood glucose at bedtime and a drop at 2 am followed by a rebound increase in the morning. Periodic blood glucose monitoring, including at night, must be performed to document the Somogyi effect. The plasma blood glucose will be less than 60 mg/dL (3.3 mmol/L) with hypoglycemia. Lethargy, confusion, thirst, nausea, flushed face, and abdominal pain are associated with hyperglycemia, not with hypoglycemia. Suggesting that the prescribed regimen was not followed is a judgmental assumption and there is insufficient information to justify this conclusion.
An adolescent child is in the terminal stage of cancer. The parents ask how they will know when death is imminent. The nurse discusses the physical manifestations with the parents. What are the signs and symptoms of approaching death? Select all that apply.
Weak pulse, Difficulty swallowing, Loss of bladder control Rationale: As the flow of blood through the body decreases, the vital centers in the brain, including the centers for thirst and appetite, become dulled; as a result, the child loses the desire for fluid and food. As nerve impulses become weaker, the entire digestive tract is slowed and the child has difficulty controlling the act of swallowing (deglutition), resulting in dysphagia; also, the gag reflex is lost. The loss of sensation and control starts in the lower extremities and progresses upward; control of the bladder and bowel is lost as loss of control reaches the trunk. As circulation slows, oxygenation and muscle tone decrease; the heart loses its contractile force, and the pulse becomes weaker and slower. Bradycardia, not tachycardia, occurs as the heart fails.
A mother expresses concern that her adolescent daughter is not ingesting enough calcium because of her allergy to milk. What alternative foods or liquids should the nurse suggest? Select all that apply.
Green leafy vegetables, Black or baked beans, Oranges, Salmon and sardines Rationale: Green leafy vegetables, black and baked beans, oranges, and salmon and sardines are all good sources of calcium even though they do not contain milk or milk products. Cottage cheese and yogurt both contain milk and therefore must be eliminated.
An adolescent with type 1 diabetes is brought to the emergency department unconscious. The blood glucose level is found to be 742 mg/dL. What clinical manifestation does the nurse expect the adolescent to exhibit during the initial assessment?
Hyperpnea Rationale: Hyperpnea (Kussmaul respirations) is an attempt by the respiratory system to eliminate excess carbon dioxide; it is a characteristic compensatory mechanism of metabolic acidosis. An increased temperature will be present only if an infection is present. Tachycardia, not bradycardia, results from the hypovolemia of dehydration associated with hyperglycemia. Hypotension, not hypertension, may result from the decreased vascular volume associated with hyperglycemia.
The mother of an adolescent girl with type 1 diabetes has a family member who died of diabetic ketoacidosis and is upset and tearful as she asks the nurse for information about her daughter's illness. What does the mother's request indicate to the nurse?
Lack of capacity to learn new information Rationale: Asking for information indicates readiness to learn. However, excessive anxiety affects the capacity to learn. The mother's question does not reflect an attitude; it indicates a desire for more information. There is not enough information to indicate that the mother is transferring her feelings about her family member to her daughter.
The mother of a 17-year-old adolescent who is going to be a foreign exchange student asks the nurse why her child must have a tetanus toxoid immunization instead of the immune globulin. The nurse responds that the tetanus toxoid immunization provides:
Longer-lasting active immunity Rationale: Toxoids are modified toxins that stimulate the body to form antibodies that can last up to 10 years against the specific disease; because the adolescent will be in a foreign country, the toxoid is given prophylactically. The tetanus toxoid provides active, not passive, immunity; all passive immunity is short acting. Only by having the disease can someone gain natural immunity. Toxoids confer active, not temporary passive, immunity.
A nurse is caring for a 13-year-old child who has an external fixation device on her leg. What is the nurse's priority goal when providing pin care?
Preventing infection: Pin sites provide a direct avenue for organisms into the bone. Pin care will not ease pain. Some scarring will occur at the pin insertion site regardless of pin site care. Skin has a tendency to grow around the pin, rather than break down, as long as infection is prevented.
A 16-year-old single mother of a 1-month-old infant and the infant's grandmother bring the baby to the emergency department and report that the infant accidentally fell down the stairs. The nurse knows that a consent form for treatment should be signed. Who has the responsibility for signing the consent?
The mother, despite her age Rationale: The client is an emancipated minor, meaning that she has adult status. In most states the age of majority is 18 years; however, parents younger than 18 years are considered emancipated minors and may sign consents for themselves and their children. Consent always is needed when a parent is present and capable of providing it. The grandmother does not have the legal right to give consent. Family court is unnecessary.
A nurse teaches a teenager who is undergoing chemotherapy about the need for special mouth care because of the potential for lesions. The nurse concludes that the instructions have been understood when the teenager says:
"I'll use a soft-bristled toothbrush to clean my teeth." Rationale: Soft bristles are less irritating to the oral mucosa and less likely to cause trauma than irritating substances are. Baking soda, mouthwash, and hydrogen peroxide are all caustic substances that may irritate the mucosa.
An adolescent is admitted to the hospital in respiratory distress, and the health care provider orders oxygen at 40% by way of a Venturi mask. The instructions for the Venturi mask indicate that delivery of 4 L/min equals 24% to 28% oxygen, delivery of 8 L/min equals 35% to 40% oxygen, and 12 L/min equals 50% to 60% oxygen. Mark where the ball of the flow meter should be raised to deliver the percentage of oxygen ordered by the health care provider.
8 Rationale: The ball of the oxygen flowmeter should be set at 8 L/min to deliver 40% oxygen through the Venturi mask.
An adolescent with terminal cancer tells the home care nurse, "I'd really like to get my GED. Do you think that's possible?" What is the best approach for the nurse to take in response to the adolescent's question?
Arranging a conference with the school and encouraging the adolescent to prepare for the test Rationale: Passing the high school equivalency test is the client's desire, and the nurse should do everything possible to help the client fulfill the goal. Refocusing the conversation on things that the adolescent has already accomplished in life is not therapeutic; the client has an unmet need, and the nurse should not try to refocus the client away from the stated objective. The client should be encouraged, not discouraged; mental activity is not too taxing and is not unrealistic if the client wishes to engage in it. There are no data supporting the conclusion that the client needs to work through feelings about the illness.
An adolescent child with sickle cell anemia is admitted to the pediatric unit during a vaso-occlusive crisis. What does the nurse identify as the reason that the crisis occurred?
Blockage of small blood vessels as a result of clumping of RBCs Rationale: The red blood cells in sickle cell anemia are fragile. When hypoxia or dehydration occurs, the cells take on a crescent shape; they then clump together and occlude blood vessels. The platelet count is not severely depressed in vaso-occlusive crisis. Diminished RBC production by the bone marrow is an aplastic crisis resulting in severe anemia. Pooling of blood in the spleen that results in splenomegaly is known as a splenic sequestration crisis.
A nurse is performing a neurologic assessment of an adolescent with a seizure disorder. How should the nurse test cranial nerve XI?
By telling the adolescent to shrug the shoulders Rationale: The accessory nerve (cranial nerve XI) innervates the sternocleidomastoid and trapezius muscles; the nurse evaluates this nerve by asking the client to shrug the shoulders. The glossopharyngeal nerve (cranial nerve IX) is assessed by stimulating the pharynx with a tongue blade. The vagus nerve (cranial nerve X) controls muscles of the larynx and is assessed by asking the client to swallow. Stroking the plantar surface of the foot is a test for the presence or absence of the Babinski reflex; this test is not used for assessment of a cranial nerve.
A 13-year-old girl tells the nurse at the pediatric clinic that she took a pregnancy test and got a positive result. She confides that her grandfather, with whom she, her younger sisters, and her mother live, has repeatedly molested her for the past 3 years. When the nurse asks the girl whether she has told anyone else, she replies, "Yes, but my mother doesn't believe me." Legally, who should the nurse notify?
Child protective services for immediate intervention Rationale: It is the nurse's legal responsibility to report child abuse to the appropriate agency. Safety is the priority, and child protective services will provide immediate intervention. Although the police may be notified, this is not the nurse's responsibility at this time. Notifying the health care provider may be done later, but it is not the priority. The girl's pregnancy has not been confirmed; at this time it is most important to protect her and her sisters.
A 15-year-old adolescent is admitted with partial- and full-thickness burns of the arms and upper torso. What are the purposes of administering pain medication by way of the intravenous route rather than the intramuscular route? Select all that apply.
It decreases the risk of tissue irritation., Severe pain is reduced more effectively., Impaired peripheral circulation is bypassed. Rationale: The medication begins to work in minutes; doses can be controlled. Intramuscular medications are avoided when possible to prevent inadequate absorption of the medication because of damaged tissue. Stating that adolescents are afraid of injections is a generalization that is not necessarily true. Decreasing the risk for tissue irritation can reduce the risk of infection, which is also one of the top care priorities after a burn injury. The duration of effectiveness of an analgesic is based on its therapeutic level in the body, regardless of what route is used.
Immediately after being placed in the supine position, an adolescent child experiences shortness of breath and must sit up to breathe. What term should the nurse use to document this clinical phenomenon?
Orthopnea Rationale: Orthopnea is shortness of breath in any position except the erect, sitting, or standing position. Apnea is a temporary cessation of breathing. Dyspnea is labored or difficult breathing regardless of the position. Hyperpnea is an increased respiratory rate, not shortness of breath.
A 15-year-old adolescent with type 1 diabetes arrives at the diabetic outpatient clinic with a parent. The adolescent sits back in the chair with arms folded, frowns, and displays a withdrawn attitude. The adolescent and parent argue in front of the nurse. What is the best approach for the nurse to use?
Speaking separately with each of them, encouraging them to recognize and vent their anger Rationale: Anger interferes with communication; recognition and ventilation of anger help to resolve it and can help increase productive communication. Anger is interfering with the acceptance of responsibility and must be addressed first. The parent and child are too angry with each other to work this out alone; they may continue to express anger toward each other, which will probably cause the conflict in their relationship to escalate. The parent should be involved with the therapy and therefore must be present when treatment is discussed.
A 16-year-old adolescent sustains an ankle injury while playing soccer. Crutches and no weight-bearing are prescribed by the practitioner. What must the nurse ensure when adjusting the crutches?
That they extend to 6 inches from the side of each foot Rationale: Having the crutches extend to 6 inches from the sides of the feet ensures the maximal base of support when the adolescent ambulates. Having the crutches reach to 1 inch below the axillae may cause trauma to the brachial plexus; the crutches should be 2 inches below the axillae. The elbows should be flexed, not extended, when the client holds the crossbars. Hunched shoulders indicate that the crutches are too short, which could result in trauma to the brachial plexus.
A 15-year-old with type 1 diabetes has a history of noncompliance with the therapy regimen. What must the nurse consider about the teenager's developmental stage before starting a counseling program?
The struggle for identity is typical. Rationale: Striving to attain identity and independence are tasks of the adolescent, and rebellion against established norms may be exhibited. Although the adolescent may be using denial, denial is not developmentally related to adolescence. This behavior is not a bid for attention; adolescents want to be like their peers and not stand out. Nor is this behavior regression; regression is the use of patterns of coping associated with earlier stages of development. Pharmacology Study Tip: Noncompliance with (or misuse of) a prescribed drug regimen is viewed as deviant behavior by health care providers. In reality, the patient may not be aware of the proper dose and regimen or may have chosen not to take the drug as prescribed for a variety of reasons.
A girl comes to the physician's office for her 14-year-old check-up. What is the most important anticipatory guidance that can be offered to the client?
Ways to prevent accidents Rationale: The biggest health risk for adolescents is accidents—they are the number-one cause of death in this age group—so anticipatory guidance during interactions with adolescents should be directed at accident prevention. Adolescents have a thought process that allows them to participate in risky behaviors because they feel as though nothing bad will ever happen to them. Although dietary issues and hygiene issues are important, they are not as important as accident prevention. All adolescents are at risk for accidents, but not all 14-year-olds are sexually active.
Which complication of anaphylactic shock in the adolescent client is most important for the nurse to detect early?
laryngeal edema Rationale: Laryngeal edema with severe acute upper airway obstruction may be life threatening in anaphylactic shock and requires rapid intervention. The reaction may also involve symptoms of irritability, tachycardia, and cutaneous signs of urticaria, but these are not as life threatening as laryngeal edema. Ensuring an open airway is priority.