Chapter 27: Growth and Development of the Adolescent: 11 to 18 Years
The nurse is assessing an adolescent's risk for harm from guns being present in the home. What question would be best to ask during the assessment? -"Are the guns in your home locked in a safe?" -"Do you and your dad hunt?" -"Have you been taught how to use a gun?" -"Do you understand that it is important for you not to handle a gun?"
"Are the guns in your home locked in a safe?" Explanation: Common causes of death in adolescents are homicide and self-harm. These are related to the easy accessibility of guns, especially when added to depression, binge drinking, and impulsivity. Gang violence and the desire to protect themselves are additional factors. Having the gun locked in a safe provides a way for limited access. Knowing how to use a gun and going hunting demonstrate expertise, but the safest way to prevent harm is to have the gun locked when not in use for these purposes. Telling the adolescent it is important not to use a gun provides no explanation why and comes across as a rule to be broken.
An adolescent who is depressed states, "Nothing ever seems to be right in my life." How should the nurse respond? "You are feeling sad right now. It is a hard time." "Things will be better when you go off to college." "Try to look at the bright side of things." "Being a teenager is hard work."
"You are feeling sad right now. It is a hard time." Explanation: Some degree of depression is present in most adolescents because they are not only losing their parents while they grow apart from them but also their carefree childhood. When using therapeutic communication, it is important for the nurse to accept the adolescent's verbalization as real. Support should be real. Telling the adolescent that things will be better in college provides false reassurance. Telling the adolescent to "look at the bright side of things" or that "being a teenager is hard work" offers platitudes and interrupts the adolescent's interactions.
An adolescent who is depressed states, "Nothing ever seems to be right in my life." How should the nurse respond? -"Things will be better when you go off to college." -"Being a teenager is hard work." -"Try to look at the bright side of things." -"You are feeling sad right now. It is a hard time."
"You are feeling sad right now. It is a hard time." Explanation: Some degree of depression is present in most adolescents because they are not only losing their parents while they grow apart from them but also their carefree childhood. When using therapeutic communication, it is important for the nurse to accept the adolescent's verbalization as real. Support should be real. Telling the adolescent that things will be better in college provides false reassurance. Telling the adolescent to "look at the bright side of things" or that "being a teenager is hard work" offers platitudes and interrupts the adolescent's interactions.
The nurse is assisting to care for a client who indicates milk is not part of their daily intake and refuses to drink it while in the hospital. The nurse is concerned about a lack of calcium in the client's diet. Which other option(s) can the nurse reinforce as good sources of calcium? Select all that apply. -soybeans -collard greens -tofu -strawberries -spinach
-tofu -soybeans -spinach -collard greens The nurse will reinforce the need for calcium in the client's diet. Consuming foods high in calcium, other than milk, is a great way for the client to receive adequate intake. Foods appropriate for the client include collard greens, spinach, soybeans, and tofu. Strawberries are high in vitamin C and antioxidants but not calcium.
An adolescent with a new piercing comes to the health center at the school. The client reports feeling hot. Which action will the nurse complete first? -Inquire about the piercing technique used. -Assess the client for signs of infection. -Determine when the client started feeling hot. -Ask the client if any other piercings are present.
Assess the client for signs of infection. Explanation: The nurse will first assess the client for signs of infection. The client reports feeling hot, which could indicate a fever. The nurse would assess the client's temperature and for other signs and symptoms of infection, such as redness, swelling, warmness, drainage, discomfort. The nurse would ask when the client started feeling hot and about the technique used for the piercing to gain additional history and insight. However, these questions are not priority over assessing the client. Determining if the client has any additional piercings is not necessary, as this will not provide information about the client's current situation.
A client has confided in a nurse that her 13-year-old daughter has recently changed dramatically in her social interactions with others. What is a social behavior most likely to be exhibited by a girl at this age? -Banding together with other girls and dressing like them -Banding together with boys and girls but maintaining her own unique style -Hanging out with girls but maintaining her own unique style -Hanging out primarily with boys her own age
Banding together with other girls and dressing like them Explanation: In early adolescence, girls tend to band together with girls. They dress identically with other members of their group: jeans and sweatshirts, special jackets, or whatever the fashion may be. On the surface, this makes adolescents appear to be losing their identities rather than finding them.
The nurse is talking with parents of a depressed 16-year-old boy. Which question is of the most importance? -Have his sleeping and eating habits changed? -How is his personal hygiene? -Is there a gun in your home? -Does he exercise?
Is there a gun in your home? Explanation: He may be at risk for suicide. Firearm-related suicides have been responsible for a large number of the suicide deaths in 15- to 19-year-olds nationwide. All the other questions assess for depression and do not protect against suicide.
What anticipatory guidance can the nurse provide the girl who has noted the development of breast buds? -Breast development will be complete with 12 months. -Adult height will be reached at the time of menarche. -The growth spurt will begin immediately with menarche. -Menarche should follow in about 2 years.
Menarche should follow in about 2 years. Explanation: Menarche usually follows within 2 years of the first signs of breast development. Peak height velocity (PVH) in girls occurs 6 to 12 months following menarche. It does not follow immediately. Breast development progresses through several stages and will not be complete until late puberty. Adult height is not reached at the time of menarche but about 6 to 12 months following menarche.
The nurse is promoting learning and school attendance for a 13-year-old girl. Which factor will affect the child's attitude most? -The dramatic changes to her body -Her parents' values and desires -Desire for attention from boys -Peer group behaviors and attitudes
Peer group behaviors and attitudes Explanation: In this age group, children have a strong desire to conform to their peer group and to be accepted. It is important to know the peer group's attitude about school and learning. Early adolescence marks the beginning of separation from the family, including its values and desires. Physiologic changes and sexual attraction would not have significant or lasting influence in this matter.
What activity would best foster the developmental task of an adolescent who uses a wheelchair to ambulate? -Allowing the adolescent to decide when to bathe -Watching television on the set in the adolescent's room -Talking to another adolescent who has a similar situation -Having a teacher bring school work to the adolescent
Talking to another adolescent who has a similar situation Explanation: A sense of identity is developed by "trying on" roles and discussing values and goals with others. A sense of trust develops when an adolescent is able to find out whom (and what ideas) to have faith in. The adolescent period is also a time where past stages of development are revisited. The sense of autonomy is where the adolescent seeks ways to express individuality. The stage of initiative is where the adolescent develops vision of what he or she might become. Talking with another adolescent who also uses a wheelchair to ambulate will help the adolescent see possibilities and reassurances. Making decisions or having assistance from someone else does not allow the adolescent to "try out" roles.
What activity would best foster the developmental task of an adolescent who uses a wheelchair to ambulate? -Watching television on the set in the adolescent's room -Talking to another adolescent who has a similar situation -Allowing the adolescent to decide when to bathe -Having a teacher bring school work to the adolescent
Talking to another adolescent who has a similar situation Explanation: A sense of identity is developed by "trying on" roles and discussing values and goals with others. A sense of trust develops when an adolescent is able to find out whom (and what ideas) to have faith in. The adolescent period is also a time where past stages of development are revisited. The sense of autonomy is where the adolescent seeks ways to express individuality. The stage of initiative is where the adolescent develops vision of what he or she might become. Talking with another adolescent who also uses a wheelchair to ambulate will help the adolescent see possibilities and reassurances. Making decisions or having assistance from someone else does not allow the adolescent to "try out" roles.
A nurse is examining a 17-year-old adolescent in the emergency room who is being disruptive in the waiting area. On assessment, the nurse finds dilated pupils, and the teen is talking very fast. Which of the following drugs does the nurse suspect the teen may be abusing? -amphetamines -opiates -marijuana -barbiturates
amphetamines Explanation: Amphetamine drug abuse can result in euphoria, rapid talking, and dilated pupils. Opiates can cause a person to be drowsy with constricted pupils. Marijuana users are usually very relaxed. Barbiturates cause euphoria that is followed by depression.
According to Erikson, the adolescent develops their own sense of being an independent person with individual thoughts and goals. This stage is referred to as: -identity vs. role confusion. -intimacy vs. isolation. -autonomy vs. doubt and shame. -industry vs. inferiority.
identity vs. role confusion. Explanation: Adolescents must develop their own personal identity—a sense of being independent people with unique ideals and goals. This is the period Erikson calls identity versus role confusion. Erikson believes during this time the adolescent goes back through all previous developmental periods to achieve this identity. The stage of autonomy versus shame and doubt occurs between 18 months and 3 years. Industry versus inferiority occurs between 5 to 12 years. Intimacy versus isolation occurs in adulthood between the ages of 19 to 40 years.
Nurses should provide anticipatory guidance to males to prepare them for what particular pubertal change in middle-to-late adolescence? -reddening of the scrotum -lengthening of the penis -pubic hair growth -nocturnal emissions
nocturnal emissions Explanation: Involuntary ejaculation during the night can be disturbing to the adolescent male who has little or no understanding of what is happening in the body. Lengthening of the penis begins to occur in early adolescence as does reddening of the scrotum and emergence of pubic hair.
An adolescent who is depressed states, "Nothing ever seems to be right in my life." How should the nurse respond? -"Being a teenager is hard work." -"You are feeling sad right now. It is a hard time." -"Try to look at the bright side of things." -"Things will be better when you go off to college."
"You are feeling sad right now. It is a hard time." Explanation: Some degree of depression is present in most adolescents because they are not only losing their parents while they grow apart from them but also their carefree childhood. When using therapeutic communication, it is important for the nurse to accept the adolescent's verbalization as real. Support should be real. Telling the adolescent that things will be better in college provides false reassurance. Telling the adolescent to "look at the bright side of things" or that "being a teenager is hard work" offers platitudes and interrupts the adolescent's interactions.
The nurse teaches parents of adolescents that teenagers need the support of parents and nurses to facilitate healthy lifestyles. What should be a priority focus of this guidance? -Reducing risk-taking behavior -Promoting adequate physical growth -Teaching personal hygiene routines -Maximizing learning potential
Reducing risk-taking behavior Explanation: The adolescent experiences drastic changes in the physical, cognitive, psychosocial, and psychosexual areas. With this rapid growth during adolescence, the development of secondary sexual characteristics, and interest in the opposite sex, the adolescent needs the support and guidance of parents and nurses to facilitate healthy lifestyles and to reduce risk-taking behaviors. Promoting physical growth, maximizing learning potential, and teaching hygiene are secondary to reducing risky behavior.
A 13-year-old girl has recently begun menstruating. She is active in sports at school. Increased intake of which of the following nutrients should the nurse recommend to the girl to prevent anemia associated with menstruation? -calcium -Iron -zinc -vitamin D
iron Explanation: Females require a high iron intake not only because of this increasing blood volume but also because iron begins to be lost with menstruation. Girls with a heavy menstrual flow (menorrhagia), especially those who participate in strenuous athletics, may need to take an additional iron supplement to prevent iron-deficiency anemia. Increased calcium and vitamin D plus physical exercise are necessary for rapid skeletal growth as well as to "stockpile" calcium to prevent osteoporosis later in life. Zinc is necessary for sexual maturation and final body growth.
The parent of a 14-year-old adolescent states to the nurse that the adolescent is moody, shuts oneself in the bedroom, and fights with a younger sibling. Which comment is most helpful to support the parent? -"Calmly talk to your adolescent about your concerns." —-"This is normal for the age." -"Take away all of the adolescent's privileges until your adolescent starts acting better." -"Set some rules for family etiquette."
"Calmly talk to your adolescent about your concerns." Explanation: Families and parents of adolescents experience changes that require adjustments and the understanding of adolescent development. The adolescent is striving for self-identity and increased independence. Thus, getting the parent and adolescent talking and sharing information is the most helpful advice. Telling the parent that this is normal does nothing for the family situation. Setting rules will likely alienate the adolescent, and taking away privileges will likely cause conflict between the parent and adolescent.
A chronically ill adolescent is readmitted to the hospital with an infected wound requiring long-term dressing changes. What is the best way the nurse can encourage independence for this client? -Have the adolescent go to the teen room every day. -Have the school provide homework. -Teach the parents to perform dressing changes at home. -Allow the adolescent to choose the time for the dressing change.
Allow the adolescent to choose the time for the dressing change. Explanation: Achieving a sense of identity may be difficult for adolescents who have a chronic illness. Some of the nursing actions which encourage identity in the chronically ill adolescent include the following: respecting food preferences; allowing the adolescent to choose the time for the dressing changes; teaching the name, actions, and possible side effects of medication; and respecting modesty. The school can provide homework so the adolescent does not get further behind in school work, and the teen can go to the teen room each day. These provide a good emotional outlet, but they do not promote independence. Teaching the parents to do the dressing changes makes the adolescent dependent on the parents. If the dressings are at a location the adolescent can reach and dexterity is not limited, then the adolescent should be allowed self-care.
An adolescent with a new piercing comes to the health center at the school. The client reports feeling hot. Which action will the nurse complete first? -Ask the client if any other piercings are present. -Determine when the client started feeling hot. -Inquire about the piercing technique used. -Assess the client for signs of infection.
Assess the client for signs of infection. Explanation: The nurse will first assess the client for signs of infection. The client reports feeling hot, which could indicate a fever. The nurse would assess the client's temperature and for other signs and symptoms of infection, such as redness, swelling, warmness, drainage, discomfort. The nurse would ask when the client started feeling hot and about the technique used for the piercing to gain additional history and insight. However, these questions are not priority over assessing the client. Determining if the client has any additional piercings is not necessary, as this will not provide information about the client's current situation.
When interviewed by the school nurse, a 13-year-old adolescent states they have a close friend of the opposite sex and that their parents do not talk about sex with them. The adolescent says they are confused about the facts and want to know the truth. Which approach best addresses this adolescent's concerns? -Offer to provide them some brochures to help them better understand how the body works. -Sit down with them and openly discuss their concerns and questions in an honest, straightforward manner. -Explain that a discussion about sex is best handled by their parents and they should go home and ask them. -Refer the adolescent to a local health department for sexual counseling and pregnancy prevention.
Sit down with them and openly discuss their concerns and questions in an honest, straightforward manner. Explanation: Discussions about human sexuality need to be open, honest, and straightforward with adolescents. Parents and health care providers must remain nonjudgmental if they want adolescents to come to them with questions. Sitting down with the adolescent and addressing their questions is the best way to establish a trusting relationship with them. Recommending that the adolescent talk with their parents will not be helpful because the parents are not open to discussing the topic. Brochures cannot answer the adolescent's specific questions and may result in more confusion. Referring the adolescent to the health department is passing the nurse's responsibility to someone else, and there is no indication that any pregnancy prevention is needed.
The nurse is admitting a 15-year-old adolescent to the hospital pediatric unit. What does the nurse recognize as a priority for this adolescent? -The adolescent's need for parental support should be discussed. -The adolescent's need for privacy should be respected. -The adolescent should be given freedom to participate in unit activities as desired. -The adolescent should be encouraged to call friends often.
The adolescent's need for privacy should be respected. Explanation: When an adolescent is ill or injured, it affects the body and body image. A hospitalized adolescent's primary concerns are pain and the loss of privacy. The adolescent is also anxious about being separated from friends and losing control of one's life. When an adolescent is hospitalized, it is very important the adolescent be given privacy. The adolescent needs individualized attention, confidentiality, and the right to participate in decisions about one's own health care. The adolescent should have contact with friends and be allowed in unit activities. Because the adolescent is under the age of 18, the parents should be involved and informed of the care. The nurse can talk with the adolescent and parents about care decisions and the adolescent's need for support from family.
The nurse is assisting in the care of a 15-year-old client during a routine annual examination. Which finding will the nurse report to the primary health care provider? -personally identifies as heterosexual -indicates little value in having friends -unsure if college is the correct future path -use of slang words when talking with the nurse
indicates little value in having friends Explanation: The nurse will report the finding of little value in friends. At this age, peer relationships are of high importance and help the adolescent develop. Not having an interest in friends indicates a deviation from normal psychosocial development and should be further assessed. It is common for adolescents to use slang words and terms when communicating. Sexual identification indicates the client is developing normally and understands himself or herself. It is common for adolescents to be unsure of their future at this age. Planning and thinking for the future are indicated and appropriate at this time. The adolescent has time to continue to explore future opportunities.
Nurses should provide anticipatory guidance to males to prepare them for what particular pubertal change in middle-to-late adolescence? -reddening of the scrotum -pubic hair growth -lengthening of the penis -nocturnal emissions
nocturnal emissions Explanation: Involuntary ejaculation during the night can be disturbing to the adolescent male who has little or no understanding of what is happening in the body. Lengthening of the penis begins to occur in early adolescence as does reddening of the scrotum and emergence of pubic hair.
The adolescent comes to the clinic seeking information about sexuality concerns. The clinic nurse assures the adolescent that confidentiality and privacy will be maintained unless a life-threatening situation occurs. Which nursing goal(s) is the nurse highlighting in this process? Select all that apply. -development of a trusting relationship -an environment where adolescents can be truthful -concern from parents who pay the office visit bill -compliance with existing laws -inappropriate response because adolescents are minors
-development of a trusting relationship -compliance with existing laws -an environment where adolescents can be truthful Adolescents may seek a health care appointment for an unrelated health concern as a reason to discuss a sexual health question with a health care professional. Reassurance should be given to the adolescent that all questions and concerns will be addressed and will be kept confidential. This is the basis for the nurse-client relationship. All questions and concerns do not involve treatment and, therefore, do not involve parental consent. Parents may voice concerns because they are responsible for the insurance and billing. The nurse should act as a client advocate and work with the parents to develop a mutual understanding of the situation. Reference:
The nurse teaches a 14-year-old client's mother about the adolescent developmental task of identity versus role confusion. What is the best way for the mother to help her adolescent complete this task? -Set limits according to what other adolescents are allowed to do. -Set limits and offer concrete choices. -Allow the adolescent to participate in decisions. -Allow the adolescent to set his/her own limits.
Allow the adolescent to participate in decisions. Explanation: Erikson describes the developmental task of adolescence as "identity versus role confusion." Adolescents must develop their own personal identities—a sense of being independent people with unique ideals and goals.
An adolescent who admits to using cocaine frequently comes to the emergency center with symptoms of chest pain, is diaphoretic, and is hypertensive. When establishing care, what priority assessment data does the nurse need? -time of last cocaine use -temperature -cardiac enzymes -heart rhythm
heart rhythm Explanation: Cocaine produces the physical effects of chest pain, increased pulse and respiration rates, increased temperature, increased blood pressure and decreased appetite. It can be a major cause of cardiovascular arrest in young adults. The priority in this situation would be to assess heart rhythm for fatal arrhythmias. The remainder of answer choices are correct, but they are not the priority.
The parents of an adolescent client are discussing puberty changes with the nurse. The parents want to best prepare their child for changes the child's body will undergo. The parents ask the nurse for guidance on how to prepare and educate their child. Which response by the nurse is appropriate? - "I can request the primary health care provider educate your adolescent if you would like." - "Wait for your adolescent to approach you and honestly answer all questions." - "It is best to provide education to your adolescent before puberty starts." -"Most adolescents learn about puberty in sex education courses in school."
"It is best to provide education to your adolescent before puberty starts." Explanation: The nurse will reinforce to the parents that they should provide education before their adolescent enters puberty to best prepare the child. Entering into puberty and experiencing body changes (e.g., menstruation, nocturnal emissions) without being properly prepared can lead to fear or feeling of shame. Questions should be answered honestly; however, the parents should be proactive and not reactive in providing education. The adolescent may not feel comfortable asking any questions without parental prompting. One cannot assume what the adolescent has or has not learned in school courses. Not all schools provide sex education courses, and the material included in these courses varies. The parents should provide open dialogue with their adolescent and not rely only on the primary health care provider. The adolescent needs to know parental support is present.
Thirteen-year-old Jeff and his mother are in the office for an annual visit. His mother jokes openly in front of the nurse about the changes in her son's voice and the fact that now he has hair under his armpits. What is an appropriate response for the nurse when she is talking with the mother? -"I felt so awkward and uncomfortable when I went through these changes." -"Discuss with Jeff about how you felt about the changes you experienced." -"Remember, he is probably very self-conscious and may be embarrassed by your statements." -"What other changes have you noticed about him beginning puberty?
"Remember, he is probably very self-conscious and may be embarrassed by your statements." Explanation: It is important for the nurse to remind the parent of how the child is feeling. It's possible that feelings resulting from their interactions will bring attention to a delicate situation. During this period, the child may become very modest and self-conscious. Adults must avoid even "good-natured" teasing because it may cause embarrassment, as the child becomes extremely sensitive about his or her body image. It is never appropriate to discuss what is happening with a client in a way that is demeaning and hurtful. The nurse can share her experiences with the client and the family but that should not lead the discussion. Parents can share their experiences with the child but they have to be open to this discussion or it can lead to an awkward experience for the adolescent.
Thirteen-year-old Jeff and his mother are in the office for an annual visit. His mother jokes openly in front of the nurse about the changes in her son's voice and the fact that now he has hair under his armpits. What is an appropriate response for the nurse when she is talking with the mother? -"What other changes have you noticed about him beginning puberty?" -"Discuss with Jeff about how you felt about the changes you experienced." -"I felt so awkward and uncomfortable when I went through these changes." -"Remember, he is probably very self-conscious and may be embarrassed by your statements."
"Remember, he is probably very self-conscious and may be embarrassed by your statements." Explanation: It is important for the nurse to remind the parent of how the child is feeling. It's possible that feelings resulting from their interactions will bring attention to a delicate situation. During this period, the child may become very modest and self-conscious. Adults must avoid even "good-natured" teasing because it may cause embarrassment, as the child becomes extremely sensitive about his or her body image. It is never appropriate to discuss what is happening with a client in a way that is demeaning and hurtful. The nurse can share her experiences with the client and the family but that should not lead the discussion. Parents can share their experiences with the child but they have to be open to this discussion or it can lead to an awkward experience for the adolescent.
Which nursing action will best assist a 15-year-old client accomplish the developmental task according to Erikson? -Allow the client's friends to visit while the client is hospitalized -Permit the client to make decision regarding one's care -Provide the client with crafts and puzzles to complete independently -Praise the client for correctly performing self-care
Allow the client's friends to visit while the client is hospitalized Explanation: The developmental task of adolescence is to develop a sense of identity, or deciding who and what kind of person one is. Friends and peers are important to facilitating the adolescent in determining one's identity. Permitting the client to make decisions assists in developing autonomy, which is a toddler task. Praising facilitates initiative, which is a preschool task. Independently performing tasks assists in developing industry, which is a school-age task.
Which nursing action will best assist a 15-year-old client accomplish the developmental task according to Erikson? -Praise the client for correctly performing self-care -Allow the client's friends to visit while the client is hospitalized -Provide the client with crafts and puzzles to complete independently -Permit the client to make decision regarding one's care
Allow the client's friends to visit while the client is hospitalized Explanation: The developmental task of adolescence is to develop a sense of identity, or deciding who and what kind of person one is. Friends and peers are important to facilitating the adolescent in determining one's identity. Permitting the client to make decisions assists in developing autonomy, which is a toddler task. Praising facilitates initiative, which is a preschool task. Independently performing tasks assists in developing industry, which is a school-age task.
The nurse is caring for a chronically ill adolescent client. When developing the plan of care for this client, which area would the nurse focus on to maintain stimulation and support the client's sense of identity while hospitalized? -Encourage keeping in contact with friends. -Instruct on the name and indications for the use of all medications. -Teach the client about food choices appropriate to the prescribed diet. -Plan interventions to fall around scheduled rest periods.
Encourage keeping in contact with friends. Explanation: To encourage stimulation while supporting the adolescent client's sense of identity while hospitalized, the nurse should encourage the client to communicate with their friends. Planning activities around rest periods does not promote stimulation. Explaining food choices does not promote stimulation. Learning about medications does not promote stimulation.
A female client tells the nurse about noticing an increase in weight and fat deposits during the past year. The nurse reviews the client's chart and recognizes that the client is most likely going through puberty. Which nursing action is most appropriate at this time? -Review dietary measures to assist in controlling weight gain. -Encourage increased exercise to control weight gain. -Provide reassurance that these are normal changes. -Share what foods can be eaten on a low-fat diet to prevent fat deposits.
Provide reassurance that these are normal changes. Explanation: Increased fat deposits and weight and height changes are normal as girls begin hormonal changes of puberty. During adolescence, girls are very sensitive about their appearance and experience a constant need for reassurance. Puberty is a period when children are very self-conscious about their overall appearance. Reassurance needs to be provided that increased fat deposits and weight and height changes are normal. Dietary management is indicated if a true weight problem is present, but healthy eating should be encouraged rather than dieting. Adolescents should be encouraged to participate in appropriate exercise programs. Dieting issues such as anorexia and bulimia can threaten the health of adolescents.
The nurse is admitting a 15-year-old adolescent to the hospital pediatric unit. What does the nurse recognize as a priority for this adolescent? -The adolescent should be encouraged to call friends often. -The adolescent's need for privacy should be respected. -The adolescent's need for parental support should be discussed. -The adolescent should be given freedom to participate in unit activities as desired.
The adolescent's need for privacy should be respected. Explanation: When an adolescent is ill or injured, it affects the body and body image. A hospitalized adolescent's primary concerns are pain and the loss of privacy. The adolescent is also anxious about being separated from friends and losing control of one's life. When an adolescent is hospitalized, it is very important the adolescent be given privacy. The adolescent needs individualized attention, confidentiality, and the right to participate in decisions about one's own health care. The adolescent should have contact with friends and be allowed in unit activities. Because the adolescent is under the age of 18, the parents should be involved and informed of the care. The nurse can talk with the adolescent and parents about care decisions and the adolescent's need for support from family.
The nurse is assisting in the care of a 15-year-old client during a routine annual examination. Which finding will the nurse report to the primary health care provider? -use of slang words when talking with the nurse -indicates little value in having friends -personally identifies as heterosexual -unsure if college is the correct future path
indicates little value in having friends Explanation: The nurse will report the finding of little value in friends. At this age, peer relationships are of high importance and help the adolescent develop. Not having an interest in friends indicates a deviation from normal psychosocial development and should be further assessed. It is common for adolescents to use slang words and terms when communicating. Sexual identification indicates the client is developing normally and understands himself or herself. It is common for adolescents to be unsure of their future at this age. Planning and thinking for the future are indicated and appropriate at this time. The adolescent has time to continue to explore future opportunities.
An 18-year-old client is planning to attend college in the fall. The health care nurse informs the adolescent that a visit with the primary care physician (PCP) will need to be scheduled before the start of college. What primary purpose does this PCP visit serve? -to update immunizations -to obtain birth control -to discuss diet -to assess for health problems
to update immunizations Explanation: The primary purpose of the PCP visit is to ensure that the adolescent has received recommended immunizations and administer any missing vaccines so that the adolescent is ready for communal living. The other answers may or may not be discussed during the visit, but they are not the primary purpose.
The nurse is selecting meal options for an adolescent client. The client is prescribed a vegan diet. Which meal option is appropriate for the nurse to select for this client? tomato sandwich, orange slices, celery with peanut butter, and 2% milk chicken noodle soup, wild rice, strawberries, and chocolate milk grilled tuna, sweet potatoes, cauliflower with ranch dip, and water tofu burger, french fries, cherry sorbet, and tea
tofu burger, french fries, cherry sorbet, and tea Explanation: A client following a vegan diet excludes all food of animal origin, including dairy products, eggs, fish, meat, and poultry. The tofu burger, french fries, cherry sorbet, and tea are all appropriate for this client. The chicken noodle soup, chocolate milk, 2% milk, and tuna are not appropriate for this client. The ranch dip is questionable because it could contain dairy. The nurse would need to request information from the dietary department for selecting the dip.
The parent of a 14-year-old adolescent states to the nurse that the adolescent is moody, shuts oneself in the bedroom, and fights with a younger sibling. Which comment is most helpful to support the parent? -"Take away all of the adolescent's privileges until your adolescent starts acting better." -"Calmly talk to your adolescent about your concerns." —"Set some rules for family etiquette." -"This is normal for the age."
"Calmly talk to your adolescent about your concerns." Explanation: Families and parents of adolescents experience changes that require adjustments and the understanding of adolescent development. The adolescent is striving for self-identity and increased independence. Thus, getting the parent and adolescent talking and sharing information is the most helpful advice. Telling the parent that this is normal does nothing for the family situation. Setting rules will likely alienate the adolescent, and taking away privileges will likely cause conflict between the parent and adolescent.
A nurse includes a health and social history for every adolescent aged 11 to 18 years when the adolescent is making their first visit to the office. Which issue(s) should the nurse address when the parent is not in the room? Select all that apply. -child abuse (child maltreatment)/intimate partner violence -sexual activities -job responsibilities -adolescent's fit in the family -substance use
-child abuse (child maltreatment)/intimate partner violence -substance use -sexual activities Explanation: A primary reason for addressing substance use, child abuse/intimate partner violence, and sexual activities while the parent is not in the room is that the adolescent may not want the parent/family member to know about these activities or the family member may be the abuser. The nurse may be able to help the adolescent develop ways of telling the parent about the issue or the adolescent may divulge the "real" reason for coming to the health care agency. The adolescent's job responsibilities and their fit in the family could all be assessed while the parent/family member is in the room.
A chronically ill adolescent is readmitted to the hospital with an infected wound requiring long-term dressing changes. What is the best way the nurse can encourage independence for this client? -Have the adolescent go to the teen room every day. -Allow the adolescent to choose the time for the dressing change. -Teach the parents to perform dressing changes at home. -Have the school provide homework.
Allow the adolescent to choose the time for the dressing change. Explanation: Achieving a sense of identity may be difficult for adolescents who have a chronic illness. Some of the nursing actions which encourage identity in the chronically ill adolescent include the following: respecting food preferences; allowing the adolescent to choose the time for the dressing changes; teaching the name, actions, and possible side effects of medication; and respecting modesty. The school can provide homework so the adolescent does not get further behind in school work, and the teen can go to the teen room each day. These provide a good emotional outlet, but they do not promote independence. Teaching the parents to do the dressing changes makes the adolescent dependent on the parents. If the dressings are at a location the adolescent can reach and dexterity is not limited, then the adolescent should be allowed self-care.
An adolescent with a new piercing comes to the health center at the school. The client reports feeling hot. Which action will the nurse complete first? -Determine when the client started feeling hot. -Assess the client for signs of infection. -Inquire about the piercing technique used. -Ask the client if any other piercings are present.
Assess the client for signs of infection. Explanation: The nurse will first assess the client for signs of infection. The client reports feeling hot, which could indicate a fever. The nurse would assess the client's temperature and for other signs and symptoms of infection, such as redness, swelling, warmness, drainage, discomfort. The nurse would ask when the client started feeling hot and about the technique used for the piercing to gain additional history and insight. However, these questions are not priority over assessing the client. Determining if the client has any additional piercings is not necessary, as this will not provide information about the client's current situation.
A 15-year-old girl is in the hospital for surgery and is confined to bed. The nurse can tell that the client is nervous about being in the hospital. She tells the nurse that she feels "gross" and "on display" in her hospital gown. What should the nurse do to encourage a sense of autonomy and dignity related to the girl's body image? -Brush the girl's hair for her. -Assist the girl with using the bed pan to urinate. -Offer to assist the girl in washing her hair and let her pick the shampoo. -Allow the girl to wear her own clothes, despite hospital policy.
Offer to assist the girl in washing her hair and let her pick the shampoo. Explanation: When caring for hospitalized adolescents, providing time for self-care, such as shampooing hair, is important to include in an adolescent's nursing care plan. Offering to assist the client in washing her hair and letting her pick the shampoo both encourages a sense of autonomy to the client and offers her dignity related to her body image. Brushing the girl's hair for her and assisting her with using the bed pan for urination do not encourage a sense of autonomy. If it is the hospital's policy to require clients to be dressed in a hospital gown while admitted, the nurse should not allow the girl to wear her own clothes.
While caring for a 16-year-old client expected to be hospitalized for several months, the nurse will perform which action to assist the client in meeting the current stage of psychosocial development? -Allow the client to touch equipment before procedures. -Explain medical concepts by providing handouts and brochures. -Permit peers to visit during open visitation hours. -Provide video games for the client to play.
Permit peers to visit during open visitation hours. Explanation: In each stage of development, a significant person or group exerts a lasting influence on the ongoing development of the child. An adolescent striving for self-identity and increased independence spends more time with peers than with family. It is important for the hospitalized adolescent to still be able to visit with peers. Video games may be enjoyed by the adolescent and limit boredom; however, this action would not facilitate psychosocial development. Allowing the client to touch equipment and to explain medical concepts/procedures are methods used to teach toddlers and preschoolers. Providing handouts and brochures are not effective methods to explain medical concepts; the nurse would verbally explain using models, pictures, and diagrams. Handouts and brochures can be used as supplements to teaching.
The nurse is admitting a 15-year-old adolescent to the hospital pediatric unit. What does the nurse recognize as a priority for this adolescent? -The adolescent's need for parental support should be discussed. -The adolescent should be encouraged to call friends often. -The adolescent's need for privacy should be respected. -The adolescent should be given freedom to participate in unit activities as desired.
The adolescent's need for privacy should be respected. Explanation: When an adolescent is ill or injured, it affects the body and body image. A hospitalized adolescent's primary concerns are pain and the loss of privacy. The adolescent is also anxious about being separated from friends and losing control of one's life. When an adolescent is hospitalized, it is very important the adolescent be given privacy. The adolescent needs individualized attention, confidentiality, and the right to participate in decisions about one's own health care. The adolescent should have contact with friends and be allowed in unit activities. Because the adolescent is under the age of 18, the parents should be involved and informed of the care. The nurse can talk with the adolescent and parents about care decisions and the adolescent's need for support from family.
The nurse instructs an adolescent on the hazards of body piercings and tattoos. Which outcome indicates that teaching has been effective? -The client limits body piercings and tattoos to areas on the trunk. -The client gets a small tattoo on the inner ankle. -The client describes the signs and symptoms to report to the provider. -The client observes a tattoo being done and decides to get one with an older brother.
The client describes the signs and symptoms to report to the provider. Explanation: Body piercings and tattoos have become a way for adolescents to make a statement of who they are and that they are different from their parents. It is important that they know the symptoms of infection at a piercing or tattoo site (e.g., redness, warmness, drainage, swelling, mild pain) and to report these to their healthcare provider if they occur because serious staphylococcal or streptococcal infections can occur at piercing sites. It is important to caution adolescents that sharing needles for piercing or tattooing carries the same risk for contacting a blood-borne disease as sharing needles for intravenous drug use. Whether or not the adolescent gets a body piercing or tattoo is their choice. But they need to be aware of what to look for if problems arise.
The nurse is selecting meal options for an adolescent client. The client is prescribed a vegan diet. Which meal option is appropriate for the nurse to select for this client? -grilled tuna, sweet potatoes, cauliflower with ranch dip, and water -tomato sandwich, orange slices, celery with peanut butter, and 2% milk -tofu burger, french fries, cherry sorbet, and tea -chicken noodle soup, wild rice, strawberries, and chocolate milk
tofu burger, french fries, cherry sorbet, and tea Explanation: A client following a vegan diet excludes all food of animal origin, including dairy products, eggs, fish, meat, and poultry. The tofu burger, french fries, cherry sorbet, and tea are all appropriate for this client. The chicken noodle soup, chocolate milk, 2% milk, and tuna are not appropriate for this client. The ranch dip is questionable because it could contain dairy. The nurse would need to request information from the dietary department for selecting the dip.
The nurse is selecting meal options for an adolescent client. The client is prescribed a vegan diet. Which meal option is appropriate for the nurse to select for this client? -tomato sandwich, orange slices, celery with peanut butter, and 2% milk -grilled tuna, sweet potatoes, cauliflower with ranch dip, and water -tofu burger, french fries, cherry sorbet, and tea -chicken noodle soup, wild rice, strawberries, and chocolate milk
tofu burger, french fries, cherry sorbet, and tea Explanation: A client following a vegan diet excludes all food of animal origin, including dairy products, eggs, fish, meat, and poultry. The tofu burger, french fries, cherry sorbet, and tea are all appropriate for this client. The chicken noodle soup, chocolate milk, 2% milk, and tuna are not appropriate for this client. The ranch dip is questionable because it could contain dairy. The nurse would need to request information from the dietary department for selecting the dip.
