HESI Patient Review--Pediatrics-Out-patient Peds (Adolescents)

15. Mark expresses concern that his sister is younger but taller than he is. Which of the following responses to Mark would be best? - ''Boys experience a growth spurt at a later age than girls." - "Your growth spurt will occur when you are more sexually mature."

"Boys experience a growth spurt at a later age than girls." This comment would relay accurate information and be appropriate. The growth spurt for boys begins about two years after the growth spurt for girls. Usually the peak growth spurt period is at about age 14. It lasts 2-3 years and generally coincides with physical sexual maturity.

7. Ashley's exam also includes assessment of pubic hair distribution. A small amount of fine straight hair is noted along her labia. Referring to Tanner's stages, Ashley's sexual maturity (pubic hair) is rated as: - Tanner Stage 1 - Tanner Stage 2 - Tanner Stage 3 - Tanner Stage 4 - Tanner Stage 5

- Tanner stage 2 Ashley is in Tanner Stage 2 for sexual maturity (pubic hair). In Tanner Stage 2 (pubic hair), pubic hair growth is sparse. Hair is straight and fine, along the labia. Stage 1 for sexual maturity (pubic hair). In Tanner Stage 1 (pubic hair), there is no pubic hair. Stage 3 for sexual maturity (pubic hair). In Tanner Stage 3 (pubic hair), pubic hair growth spreads from the labia over the symphysis pubis. Hair is darker, coarser, and curlier than that in Tanner Stage 2. Stage 4 for sexual maturity (pubic hair). In Tanner Stage 4 (pubic hair), pubic hair growth covers a wider area than in Tanner Stage 3. Stage 5 for sexual maturity (pubic hair). In Tanner Stage 5 (pubic hair), pubic hair growth is mature, spreading on the medial surfaces of the thighs.

14. Referring to Tanner's stages, Mark's sexual maturity is rated as: - Tanner Stage 1 - Tanner Stage 2 - Tanner Stage 3 - Tanner Stage 4 - Tanner Stage 5

- Tanner stage 2 Mark is correctly rated in Tanner Stage 2 for sexual maturity. In Tanner Stage 2, there is enlargement of the scrotum and testes, but the penis is not enlarged. The scrotal skin is reddened and there is a sparse growth of long slightly pigmented downy hair at the base of the penis. Stage 1 for sexual maturity. In Tanner Stage 1, the penis and testes are prepubertal without pubic hair. Stage 3 for sexual maturity. In Tanner Stage 3, the testes and scrotum continue to enlarge, and the penis increases in length. Pubic hair becomes coarse and curly, and extends across the pubis. Stage 4 for sexual maturity. In Tanner Stage 4, there is further enlargement of the testes and scrotum, and the penis increases in length and circumference. Pubic hair increases in area but does not extend to the thighs. Stage 5 for sexual maturity. In Tanner Stage 5, pubic hair extends to the medial surfaces of the thighs.

19. Mrs. Johnson becomes agitated and says "I'm already late for work, these physicals have taken so long! Can't I read these later and mail them back to you?" Which response on your part is best? - "Yes, that will be OK." - "If you sign the forms now and promise to read copies later, then that will be OK." - "I'm sorry, I cannot administer the vaccines to your children until you have read and signed the forms." - "I think your children are more important than your job."

"I'm sorry, I cannot administer the vaccines to your children until you have read and signed the forms." This response is appropriate. Federal law requires that a parent or guardian read vaccine information sheets, ask questions, and sign appropriate forms before vaccines are administered to children.

22. Which question is appropriately asked of Ashley at this time? - "Is there anything causing you to be sad or depressed?" - "What is the ideal weight you would like to achieve?" - "What do you think about your size and weight?" - "What do your friends think about your weight?"

"What do you think about your size and weight?" It is most important to assess whether Ashley has a realistic view of her size and weight. Ashley is presenting with signs of anorexia nervosa. Individuals with anorexia nervosa have an unrealistic view of their size and weight. Their body image is distorted.

27. To meet Ashley's nutritional needs, which of the following approaches are appropriately implemented? (Select 2) - Ashley and her family members work on her nutritional plan together - Ashley is expected to monitor her own diet and keep a diary of her eating habits - A diet that includes mostly high-calorie carbohydrates is recommended - Ashley loses social privileges when she fails to eat adequately

-Ashley and her family members work on her nutritional plan together Ashley will be more compliant if her nutritional plan is developed with her input, as well as input from family members. All family members should be involved in nutritional planning, since eating is often done as a family group. Ashley will be encouraged to eat three meals a day at regular times. -Ashley is expected to monitor her own diet and keep a diary of her eating habits Expecting Ashley to monitor her own progress and keep a diary of her eating habits is appropriate. This should help give her a sense of control. Anorexia nervosa is often an attempt to have a feeling of control.

28. Which of the following nutritional guidelines are correct and included as part of Ashley's nutritional counseling? (Select 3) - Nutritional needs are greatest during late adolescence - Weight gain for Ashley should be gradual, about 3-5 pounds per week - Caloric intake should come from a combination of fats, proteins, and carbohydrates - Intake of sugars (simple carbohydrates) and saturated fats should be limited - Whole grain selections are preferred from the bread/cereal/rice/pasta group - Calcium and iron supplements are often needed for adolescents

-Caloric intake should come from a combination of fats, proteins, and carbohydrates For Ashley, and all adolescents, daily calories should come from a combination of carbohydrates, fats, and proteins, taken from all food groups. Although modifications might be suggested for Ashley (based on her current nutritional needs), 30-35% of calories should come from fats, 15% of calories should come from proteins, and 50-55% of calories should come from carbohydrates. -Intake of sugars (simple carbohydrates) and saturated fats should be limited Sugars are a concentrated source of calories, with little nutritional value. Saturated fats raise cholesterol level. Therefore, intake of these should be limited, in all age groups. Unsaturated fat sources include fish, nuts, and vegetable oils. -Whole grain selections are preferred from the bread/cereal/rice/pasta group Whole grains are an especially good source of fiber, which contributes to bowel health. 6-11 servings of food from the bread/cereal/rice/pasta group are recommended for adolescents. Foods in this group are complex carbohydrates.

30. Which of the following interventions are appropriately implemented? (Select 6) - Consent for sexually transmitted disease (STD) treatment is obtained from Ashley's mother - Education regarding the importance of condom use for the prevention of HIV and sexually transmitted diseases (STDs) - Antibiotic therapy for Ashley - Antibiotic therapy for Ashley's boyfriend - Education regarding increased risk of pelvic inflammatory disease and fertility problems - Emphasis on completing treatment and avoidance of sexual intercourse until treatment is completed - Discussion of abstinence from sexual intercourse as an option in avoiding sexually transmitted diseases (STDs) and the only 100% birth control method

-Education regarding the importance of condom use for the prevention of HIV and sexually transmitted diseases (STDs) -Antibiotic therapy for Ashley -Antibiotic therapy for Ashley's boyfriend -Education regarding increased risk for pelvic inflammatory disease and fertility problems -Emphasis on competing treatment and avoidance of sexual intercourse until treatment is completed - Discussion of abstinence from sexual intercourse as an option in avoiding sexually transmitted diseases (STDs) and the only 100% birth control method Adolescents can be diagnosed and treated for sexually transmitted diseases (STDs) and pregnancy without consent from parents. Ashley's parents should not be told about her sexual activities and health problem without her consent.

10. The adolescent's right to confidentiality is designed to: (Select 2) - encourage the adolescent to seek healthcare and advice without fear - support the adolescent's growing sense of autonomy - keep information from judgmental parents - help the adolescent keep secrets about her social and sexual activities from her parents

-Encourage the adolescent to seek healthcare and advice without fear Fear that disclosure of information to parents or legal authorities will occur is a primary reason that adolescents avoid seeking health care and advice. It is important that adolescents know that the information they provide will be confidential. In most states, confidentiality laws cover contraception, pregnancy, abortion, sexually transmitted diseases (STDs), and drug counseling. The healthcare professional should be familiar with the state laws concerning confidentiality. Under these laws, an adolescent can obtain pregnancy testing, abortion services, and treatment for STDs without the consent of parents. -Support the adolescent's growing sense of autonomy Adolescents have a growing need for autonomy. This need can be supported by allowing the adolescents privacy and respect for their decisions

20. Which of the following are possible contributing factors to the development of acne in adolescents? (Select 5) - "Fatty" foods - Environmental irritants - Chocolate - Androgens - Hereditary factors - Menstrual cycle - Poor hygiene

-Environmental irritants -Androgens -Hereditary factors -Menstrual cycle -Poor hygiene

24. Priority nursing diagnoses that apply to Ashley at this time include: (Select 3) - Ineffective Coping related to disturbed peer relationships - Imbalanced Nutrition: Less Than Body Requirements related to refusal to eat enough food to supply adequate calories - Disturbed Self-Concept related to inaccurate perception of self as "flabby" and "fat" - Risk for hypothermia related to decreased subcutaneous tissue

-Imbalanced Nutrition: Less Than Body Requirements related to refusal to eat enough food to supply adequate calories Malnutrition is life-threatening and Ashley's most critical problem at this time. Addressing this physiological nursing diagnosis takes top priority. -Disturbed Self-Concept related to inaccurate perception of self as "flabby" and "fat" Ashley's disturbed self-concept plays a primary role in her health problem and must be addressed as a top priority. -Risk for hypothermia related to decreased subcutaneous tissue Risk for Hypothermia applies as a nursing diagnosis for Ashley. Ashley's recent temperature reading of 36 degrees C (96.8 degrees F) reflects a body temperature lower than normal, but not at a level that defines hypothermia (35.5 degrees C / 96 degrees F). However, because she is so thin and has little subcutaneous tissue, and has a slow metabolic rate, she is at risk for having hypothermia. Ashley can be taught measures to help avoid hypothermia while she is so thin (wearing gloves and socks, taking warm baths, drinking warm fluids, etc.). This nursing diagnosis does not apply at this time. Ashley may or may not be coping effectively. Her anorexia nervosa may be associated with ineffective coping. However, her coping skills have yet to be evaluated. Also, there is no data yet with regard to her peer relationships

23. Which of the following, evident with Ashley, are consistent with anorexia nervosa? (Select 4) - Low body temperature - Tachycardia - Dry skin and brittle nails - Weight loss despite increase in stature - Irregular menses

-Low body temperature With anorexia nervosa, a decreased caloric intake causes a slowed metabolic rate. A slow metabolic rate causes body temperature to be lower than normal. -Dry skin and brittle nails With anorexia nervosa, nutritional deficiencies are common. Skin becomes dry, and nails become brittle. -Weight loss despite increase in stature Weight is expected to increase during growth spurts of increased stature. Weight loss during periods of growth is cause for concern, and often characterizes anorexia nervosa. -Irregular menses Irregular periods or secondary amenorrhea (the absence of menses after menarche) is often present in adolescent girls with anorexia nervosa. With a pulse rate of 54 beats per minute, Ashley has bradycardia, not tachycardia. With anorexia nervosa, a decreased caloric intake causes a slowed metabolic rate, and bradycardia is often noted. Blood pressure may also be low.

13. Taking a preventive approach, you discuss with Ashley some of the risks associated with smoking, alcohol, and drug use. Which of the following are accurately included in your discussion? (Select 4) - Many young people who try cigarettes become regular users - The younger a person is when she starts smoking, the harder it is to quit smoking in the future - The younger a person is when she starts smoking, the greater the chance of developing serious health problems - If only a few cigarettes are smoked a day, it is not hard to quit smoking - Once drugs or alcohol are used, it becomes very hard to quit

-Many young people who try cigarettes become regular users Of the youth that try cigarettes, many become regular users. Ashley should be told this -The younger a person is when she starts smoking, the harder it is to quit in the future The younger a person is when smoking begins, the stronger the addiction, and the harder it is to stop smoking. Ashley should be told this. -The younger a person is when she starts smoking, the greater the chance of developing serious health problems Health problems associated with smoking begin sooner and are generally more serious in persons who started smoking at younger ages. Ashley should be told this. -Once drugs or alcohol are used, it becomes very hard to quit When adolescents use alcohol and drugs early in their teen years, the more likely it is that dependence and addiction will develop. It is important that Ashley know that it is important not to experiment with alcohol and drugs. If she does start using drugs and alcohol, it is likely she may become dependent and have difficulty stopping.

11. As Ashley and Mark experience their adolescent years, risk-taking and risk for injury may increase. This is because adolescents: (Select 4) - may test their independence from parents by participating in behaviors disapproved of by parents - often feel indestructible and invincible - tend to participate in and prefer solitary activities - tend to strictly adhere to rules and regulations - have a strong need for peer approval - frequently have a strong desire to impress parental figures - have a strong need to discharge energy

-May test their independence from parents by participating in behaviors disapproved of by parents It is true that adolescents often test their independence by acting in ways that are not supported by their parents. Often, the behaviors they choose are high-risk. As adolescents transition into young adulthood, they try out various roles in an effort to gain an understanding of their identity. -Often feel indestructible and invincible Adolescence is a time when many young men and women feel immortal and indestructible. This contributes greatly to risk-taking behavior and risk for injury. -Have a strong need for peer approval Adolescents display increasing resistance to parental demands during adolescence, as the peer group gains importance. The peer group is essential to an adolescent as he attempts to meet the standards and expectations of the group. The peer group, rather than objectivity and good judgment, provides the frame of reference for the adolescent. Therefore, his decisions may not always be appropriate. The ultimate goal of the adolescent is to become emancipated from parents. -Have a strong need to discharge energy Adolescence is a time of high energy levels. Increased activity level often increases risk for injury. Adolescents tend to participate in group activities, rather than solitary activities. An adolescent is probably more likely to participate in high-risk behaviors when others are doing the same. Although participation in sports is worthwhile, athletic activity does increase risk for injury. Proper protective gear should be worn and safe technique should be practiced at all times. Many adolescents do not feel a strong need to adhere to rules. Adolescents often begin to test their independence by breaking established rules. Many rules are established to insure safety. Breaking of rules often increases risk for injury. In the adolescent years, the need to impress peers outweighs the desire to impress parents.

21. Mark has received advice regarding acne from his school nurse. Which advice was correct? (Select 2) - Avoid soda, chocolate, and fried food - Scrub skin vigorously three times daily - Practice stress management techniques - Avoid squeezing or popping pimples

-Practice stress management techniques Stress tends to increase the severity of acne. Stress-reducing activities, such as relaxation, can be utilized by the adolescent. -Avoid squeezing or popping pimples Except for skin cleansing, and any prescribed medication, acne should be left alone. Touching, squeezing, or popping pimples can lead to inflammation and scarring and should be avoided. Many acne treatments can take 2-3 months to be effective. Acne may actually get worse before it gets better.

29. Ashley's sexual high-risk behavior, engaging in unprotected sexual intercourse, puts her at risk for which of the following? (Select 6) - Pregnancy - Trichomonas vaginalis - Chlamydia trachomatis - Gonococcal infection - Toxic shock syndrome - Herpes simplex virus type 2 - Human Immunodeficiency Virus (HIV) infection

-Pregnancy -Trichomonas vaginalis -Chlamydia trachomatis -Gonococcal infection -Herpes simplex virus type 2 -Human Immunodeficiency Virus (HIV) infection

5. For boys, Tanner's sexual maturity ratings evaluate: (Select 4) - pubic hair growth and distribution - onset of seminal emissions - penis growth and development - testes growth and development - scrotum growth and development

-Pubic hair growth and distribution For boys, Tanner's sexual maturity ratings evaluate pubic hair growth and distribution. The location, density, and coarseness of pubic hair help define the stage of sexual maturity. -Penis growth and development The size and shape of the penis are evaluated as part of Tanner staging. -Testes growth and development The size and shape of the testes are evaluated as part of Tanner staging. -Scrotum growth and development The size and shape of the scrotum, and the color and texture of scrotal skin, are evaluated as part of Tanner staging. The ability to ejaculate semen (have seminal emissions) signals male puberty. However, the ability to have seminal emissions is not considered for Tanner staging.

4. For girls, Tanner's sexual maturity ratings evaluate: (Select 2) - pubic hair growth and distribution - breast changes and growth - onset of menarche - behavioral changes

-Pubic hair growth and distribution For girls, Tanner's sexual maturity ratings evaluate pubic hair growth and distribution. The location, density, and coarseness of pubic hair help define the stage of sexual maturity. -Breast changes and growth For girls, Tanner's sexual maturity ratings evaluate breast changes and growth. Changes in nipples and areola are considered. Changes in breast size and contour are also evaluated. These changes help define the stage of sexual maturity.

6. Referring to Tanner's stages, Ashley's sexual maturity (breasts) is rated as: - Tanner Stage 1 - Tanner Stage 2 - Tanner Stage 3 - Tanner Stage 4 - Tanner Stage 5

-Tanner stage 2 Ashley is correctly rated in Tanner Stage 2 for sexual maturity (breasts). Tanner Stage 2 is the breast bud stage. A small mound of breast tissue is present. Nipples are elevated. The diameter of each areola is enlarged. As breast tissue develops, some soreness may be felt. Tanner Stage 1 is prepubertal. Nipples are present and elevated. Glandular breast tissue is not present. Tanner stage 3, breasts are larger and have more elevation. Each areola is in contour with the breast tissue. Tanner stage 4, breasts are larger and each areola projects from the breast contour. Tanner stage 5, breasts are mature, with nipple projection and some receding of each areola to the general contour of the breast.

8. Ashley wants to know when she will get her "period." You correctly tell her that there is no way of knowing for sure, but commonly menstruation begins: - a few months after breast tissue starts to develop - 1-2 years after breast tissue starts to develop - at age 13 years - when pubic hair appears

1-2 years after breast tissue starts to develop Menstruation (menarche) usually occurs within two years of the start of breast tissue development and the appearance of pubic hair. Menstruation usually coincides with physical sexual maturity.

16. Mark is 144.8 cm (57 inches) tall and weighs 41 kg (90 pounds). Using a clinical growth chart for boys 2-20 years (Stature-for-age and Weight-for-age), what percentiles is Mark in for stature and weight? (Select growth chart button at left to view relevant growth chart.) - 10th percentile for stature, 25th percentile for weight - 25th percentile for stature, 50th percentile for weight - 50th percentile for stature, 25th percentile for weight - 15th percentile for stature, 15th percentile for weight

25th percentile for stature, 50th percentile for weight Using a clinical growth chart for boys 2-20 years (Stature-for-age and Weight-for-age), Mark falls at the 25th percentile for stature, and roughly the 50th percentile for weight.

26. In working with Ashley, it is also important to realize that she can reason and problem-solve. She can think about possibilities, as well as future consequences related to her actions. This kind of thinking ability is called: - concrete thinking - abstract thinking

Abstract thinking According to Piaget's Cognitive Theory of Development, adolescents (12-15 years) begin to think in abstract terms and refine their problem-solving skills. They begin to contemplate abstract ideas and concepts such as religion, truth, and justice. They become able to think about the possible future outcomes of their behaviors.

2. Ashley and Mark are prepubescent, meaning that they are: - beginning to develop physical secondary sex characteristics - at the peak of achieving mature physical secondary sex characteristics - sexually mature - capable of reproduction

Beginning to develop physical secondary sex characteristics Prepubescent adolescents experience hormonal changes that cause their reproductive organs to start functioning. Physical maturation is noted in the beginning development of secondary sex characteristics.

1. Ashley (11 years) and Mark (12 years) are both considered adolescents. Adolescence includes three developmental phases: early, middle, and late adolescence. Ashley and Mark are in which phase of adolescence? - Early adolescence - Middle adolescence - Late adolescence

Early adolescence Maturing females and males 11-14 years of age are considered in early adolescence. Early adolescence is the beginning of the transition period between childhood and early adulthood. During adolescence, sexual, psychological, and social maturation occur gradually. Maturing females and males 14-17 years of age are considered in middle adolescence. Maturing females and males ages 17-20 years of age are considered in late adolescence.

25. Ashley's stage of psychosocial development (almost 14 years) should be understood as she is treated for her health problem. According to Erikson, in which psychosocial stage of development is Ashley? - Autonomy vs. Shame and Doubt - Initiative vs. Guilt - Trust vs. Mistrust - Identity vs. Role Confusion

Identity vs. Role confusion Identity vs. Role Confusion is the stage that occurs from 12-20 years during which the task of developing a sense of self is accomplished. In this stage, the adolescent is attempting to define her own identity. Identity becomes central during adolescence as physical, social, and cognitive development progresses. Helping Ashley develop a positive sense of self is critical at this time for her psychosocial development and the resolution of her health problem.

12. Because Ashley is not currently participating in any high-risk behaviors, you should: - defer any discussion of high-risk behaviors, so as not to give Ashley any ideas - initiate a discussion of high-risk behaviors and their consequences, in hope of preventing them

Initiate a discussion of high-risk behaviors and their consequences, in hope of preventing them An anticipatory guidance and preventive approach should be taken with Ashley. It is likely that she will be exposed to many possibilities for high-risk behaviors. Knowledge about these and possible consequences will possibly make Ashley think twice before choosing to participate in high-risk activity.

17. To determine Mark's weight status category, which of the following is used? - Mark's body weight of 41 kg - Mark's body weight percentile at 50% - Mark's body mass index (BMI) of 19.6 - Mark's body mass index (BMI) percentile at 75%

Mark's body mass index (BMI) percentile at 75% For adolescents, body mass index (BMI) percentile is used to determine weight status category.

31. Which approach is best to take with Mark at this time? - Advise Mark that his drinking will take him nowhere and is unacceptable - Praise Mark for his courage in telling you about his fear of alcohol "binging" - Schedule an appointment for Mark to meet with a psychiatrist to discuss coping skills - Encourage Mark to join Alcoholics Anonymous

Praise Mark for his courage in telling you about his fear of alcohol "binging" Praising Mark for sharing his fears should enhance his self-esteem and encourage him to continue talking with you. If he knows you are concerned and not judgmental, he will be more likely to listen to your advice about high-risk behaviors that can lead to injury to self and/or others.

3. Which of the following will be used to assess physical sexual maturity? - Clinical growth charts for (female and male) children and adolescents age 2-20 years - Tanner stages - Body surface area (BSA) - Body mass index (BMI)

Tanner stages Five stages of sexual maturity, as described by Tanner, are useful for assessing physical sexual maturity. Both Ashley and Mark will be examined and their stages of sexual maturity, as defined by Tanner, will be determined.

9. You review Ashley's immunization history with her mother. Ashley has not received the hepatitis B vaccine series. Which of the following approaches is likely to be taken by the Nurse Practitioner today? - Since hepatitis B is only a threat to infants, Ashley will not need the vaccine - The hepatitis B vaccine series will be started today - Since the hepatitis B vaccine series will be required for high school, the vaccine series will be started at a later date

The hepatitis B vaccine series will be started today Although Ashley is not required to have the hepatitis B vaccine series until high school in her community, the vaccine should not be delayed. It is likely that the hepatitis B vaccine series will be started today. Hepatitis B is a serious communicable health problem caused by the hepatitis virus. It can spread from an infected person to others by means of blood, body fluids, and intimate sexual contact. Hepatitis B is a special threat to adolescents who may be sexually active and/or using drugs. Chronic hepatitis B infection can occur in some individuals, who then become carriers of the infection. The likelihood of becoming chronically infected is especially high in infants and young children who are infected. Chronic hepatitis B infection causes liver damage and increases risk of liver cancer.

18. Mark has a cold. Should he receive vaccines at this visit? - No, Mark should not be immunized at this visit - Yes, Mark should be immunized at this visit

Yes, Mark should be immunized at this visit Immunizations may be withheld for moderate or severe infections. Immunizations are not postponed for a minor illness like a cold.