Ch. 36 (Ped1)
3) 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.
10) 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.
5) 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.
1) 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.
15) 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.
20) Which question is appropriate for the nurse to include in the assessment for an adolescent client related to[B1] 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?" [B1]Erin--edit OK?
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.
13) 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.
14) 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.
6) 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.
7) 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. 4. The nurse can ask general questions about seat belt use, academic performance, and school friends without breaching confidentiality.
2) 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.
12) 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.
19) 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.
9) 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.
4) 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.
8) 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.
16) 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.
18) 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.
11) 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.
17) 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.