Adolescent NCLEX

Which symptom reported by an adolescent's parents indicates that the adolescent is abusing amphetamines?

1. Restlessness, 3. Excessive perspiration, 4. Talkativeness

An otherwise-healthy adolescent has meningitis and is receiving I.V. and oral fluids. The nurse should monitor this client's fluid intake because fluid overload may cause:

1. cerebral edema

The parent of a 16-year-old client with diabetes mellitus tells the nurse that she doesn't allow her adolescent to attend any functions with the opposite sex. The nurse should respond to the parent based on her knowledge of adolescent behavior, which suggests that:

1. the adolescent may feel isolated without the opportunity to develop relationships with the opposite sex.

A 14-year-old client with type 1 diabetes is admitted with ketoacidosis for the second time in 3 months. The mother states, "I don't know why this keeps happening." Which response by the nurse is best?

2. "Adolescents sometimes become overwhelmed by having to adhere to dietary restrictions and taking medications.

At what age should boys be taught how to do a monthly testicular self-examination?

2. 12 years old

The nurse is preparing a 13-year-old client for the operating room where she'll undergo an appendectomy. Which approach by the nurse is most effective for this age-group?

2. Providing simple, straightforward, age-appropriate explanations about the procedure

A child, age 14, is hospitalized for nutritional management and drug therapy after experiencing an acute episode of ulcerative colitis. Which nursing intervention would be appropriate?

2. Providing small, frequent meals

A teenager is brought to the facility by friends after accidentally ingesting gasoline while siphoning it from a car. Based on the nurse's knowledge of petroleum distillates, which system would be most affected?

2. Respiratory system

As an adolescent is receiving care, he's inadvertently injured with a warm compress. The nurse completes an incident report based on the knowledge that identification of which of the following is a goal of the report?

2. To identify the learning needs of staff to prevent incident recurrences

The nurse is caring for an adolescent client who underwent surgery for a perforated appendix. When caring for this client, the nurse should keep in mind that the main life-stage task for an adolescent is to:

2. develop an identity and independence.

Which statement by a female adolescent reveals an early indicator of anorexia nervosa?

3. "I jog three times per day for a total of 5 hours per day."

After collecting data on an adolescent with sickle cell anemia, the nurse assists with formulating a nursing diagnosis of Impaired skin integrity. Which finding best supports this nursing diagnosis?

3. Leg ulcers

An adolescent, age 17, with acute lymphoblastic leukemia is discharged with written information about chemotherapy administration and the outpatient appointment schedule. The child now is in the maintenance phase of chemotherapy but has missed clinic appointments for blood work and admits to omitting some chemotherapy doses. To improve the client's compliance, the nurse should include which intervention in the plan of care?

3. Letting the client participate in the planning and scheduling of treatments

The nurse is caring for an adolescent, age 14. Which emotional response is typical during early adolescence?

3. Moodiness

The nurse observes a gun under the jacket of a visitor who's visiting a 17-year-old client. Which action should the nurse take first?

3. Notify security immediately.

Which finding would likely indicate that an adolescent is experiencing pain?

3. Restlessness

The nurse is caring for a teenage client involved in a motor vehicle accident. The client has a chest tube in place. If the chest tube is accidentally removed, the nurse should immediately:

3. cover the opening with sterile petroleum gauze.

A child, age 14, is diagnosed with scoliosis and scheduled for brace application. The mother asks the nurse how long her child will have to wear the brace. What is the nurse's best response?

4. "About 4 to 7 years."

A 15-year-old girl visits the neighborhood clinic seeking information on "how to keep from getting pregnant." What should the nurse say in response to her request?

4. "Can you tell me about the precautions you're taking now?"

A 15-year-old girl at the health clinic says she's considering having a sexual relationship with her boyfriend. She tells the nurse that she's on birth control pills so she doesn't have to worry about pregnancy or HIV. What's the appropriate response from the nurse?

4. "The most effective way to avoid acquiring HIV or becoming pregnant is abstinence. The pill won't protect you from getting HIV, and isn't 100% accurate for preventing pregnancy."

A 15-year-old client comes to the clinic for treatment of an upper respiratory infection. When the nurse exposes the client's arm to obtain her blood pressure, she notes bruising that appears to be in the shape of fingers. The nurse questions the client about the bruises and the client begins to cry, saying, "Please don't tell anyone. My boyfriend didn't mean to hurt me." Which response by the nurse is best?

4. "This abuse can't be kept secret; let's devise a safety plan. Do you have an adult you can turn to?

A 15-year-old tells her parents that she was offered a babysitting job after school. Which response by the parents best helps the adolescent make a decision about taking the job?

4. "What thought have you given as to how you'll manage school, babysitting, and your other responsibilities?"

The school nurse is planning a program for a group of teenagers on skin cancer prevention. Which of the following instructions should the nurse emphasize in her talk?

4. Examine skin once per month, looking for suspicious lesions or changes in moles.

A 14-year-old female client in skeletal traction for treatment of a fractured femur is expected to be hospitalized for several weeks. When planning care, the nurse should take into account the client's need to achieve what developmental milestone?

4. Identity

A child, age 13, is being evaluated for possible Crohn's disease. The nurse expects to prepare the child for which diagnostic study?

4. Sigmoidoscopy

When evaluating a severely depressed adolescent, the nurse knows that one indicator of a high risk for suicide is:

4. a preoccupation with death.

The nurse is interviewing a 16-year-old female at a clinic. It's her first visit and she says that she has been exposed to herpes by her boyfriend. Initially, with primary genital or type 2 herpes simplex, the nurse would expect the client to have:

4. burning or tingling on the vulva, perineum, or vagina.

An adolescent with ulcerative colitis hasn't responded to nutritional intervention and drug therapy. During data collection, the nurse expects to note:

4. delayed sexual development

A group of 16-year-olds are eating at a restaurant. One adolescent starts to cough. He puts his hands around his neck to gesture that he can't breathe. A friend stands and positions himself to begin the Heimlich maneuver. Identify the area where it's most appropriate to place the hands when performing the Heimlich maneuver.

To perform the Heimlich maneuver, the hands should be placed on the abdomen, just above the navel.

A 15-year-old female with a urinary tract infection (UTI) is admitted to the facility. She tells the nurse she hopes that she's pregnant. Which of the following would be the best response by the nurse?

2. "Tell me what pregnancy would mean to you."

A 13-year-old boy visits the school nurse because he's experiencing back pain, fatigue, and dyspnea. The nurse suspects that the child may have scoliosis. The nurse should first:

2. inspect the child for uneven shoulder height or uneven hip height.

A 15-year-old boy wants to try out for the football team. His parents are concerned that, because he's small for his age, he might be subjecting himself to ridicule. Which response by the parents best supports the adolescent's decision-making process?

2. "Whether or not you play football is your decision; tell us why you want to play."

An adolescent with type 1 diabetes mellitus is experiencing a growth spurt. Which treatment approach would be most effective for this client?

2. Administering multiple doses of insulin

The nurse is preparing to teach a 13-year-old client with asthma to administer his own breathing treatments. Which principle should the nurse keep in mind when planning the teaching session?

2. Adolescents are worried about appearing different from their peers.

A 15-year-old client who sustained a spinal cord injury is on bedrest. Which intervention by the nurse might best help the adolescent cope with the prolonged bedrest?

2. Encouraging visitation by his friends

An adolescent is admitted with a diagnosis of nephrotic syndrome. Which signs or symptoms would the nurse expect to see with this syndrome?

2. Hypercholesterolemia, 3. Hypoproteinemia, 4. Proteinuria, 5. Periorbital edema

A 14-year-old client diagnosed with acne vulgaris asks what causes it. Which factors should the nurse identify for this client?

2. Increased hormone levels, 3.Growth of anaerobic bacteria, 5. Heredity

The nurse should encourage an adolescent girl to increase her dietary intake of which nutrient to help meet the increased nutritional requirements of menstruation?

2. Iron

The nurse is caring for a 16-year-old female client who isn't sexually active. The client asks if she needs a Papanicolaou (Pap) test. The nurse should reply:

2. no because she isn't sexually active.

A girl, age 13, is admitted with anorexia nervosa. The charge nurse has formulated a nursing diagnosis of Disturbed body image. What assessment data would support this diagnosis?

2. She states, "I'm afraid to eat because I'll gain weight."

During a health teaching session, a student, age 14, asks the school nurse the reason for using underarm deodorant. The nurse should base the response on which physiologic change occurring during adolescence?

2. The apocrine sweat glands reaching secretory capacity

A 14-year-old child with diabetes checks his blood glucose at 9:00 p.m. before going to bed. It has been 4 hours since his dinner and his regular insulin dose. His blood glucose is 60 mg/dl, and he states that he feels a little shaky. Which of the following should the nurse suggest?

1. A snack of an 8-oz glass of milk and graham crackers with peanut butter before going to sleep

The nurse is teaching a group of adolescents about proper nutrition. The nurse should explain that it's necessary to increase intake of which nutrients?

1. Calcium, 2. Vitamin D, 3. Iron, 4. Protein

An emancipated adolescent is pregnant and plans to raise her child. She has no income or health insurance. Which recommendation should the nurse make to help the client with her health care expenses?

1. Completing a Medicaid application

An overweight girl, age 15, has lost 12 lb (5.4 kg) in 8 weeks by dieting. Now, after reaching a weight plateau, she has become discouraged. She and the nurse decide she should keep a food diary. What is the primary purpose of keeping such a diary?

2. To help the nurse and client analyze the amount of food the client is eating and determine when food intake occurs

A 16-year-old client comes to the physician's office for a physical examination that's required to play sports. The mother reports that her son is unusually tired during the day. She explains that he works at a part-time job, is socially active, and gets about 7 hours of sleep each night. Physical examination reveals that the client grew 3" during the past year. Which intervention by the nurse is most appropriate?

1. Explaining that his sleep requirements have increased related to the increased metabolic demands of growth

An adolescent typically achieves formal operational thought, Piaget's final stage of cognitive development. Which cognitive abilities are achieved during this stage?

1. Flexibility, 2. Complex deductive reasoning, 5. Abstract thinking

When developing a plan of care for an adolescent, the nurse considers the child's psychosocial needs. During adolescence, psychosocial development focuses on:

2. establishing an identity.

A 17-year-old client comes to the clinic requesting treatment for a suspected sexually transmitted disease. He's concerned that his parents will be notified of his request for treatment. Which response by the nurse is most appropriate?

2. "Can you tell me your understanding of the implications of diagnostic testing and treatment?"

During chemotherapy for lymphoma, a child, age 15, is at risk for stomatitis. Which statement by the child supports a nursing diagnosis of Deficient knowledge related to mouth care?

2. "I remove white patches on my tongue and cheeks with my toothbrush."

The nurse is teaching a group of adolescent girls about personal hygiene. Which statement by an adolescent indicates the need for further teaching?

2. "It's unsafe to bathe during your period."

An adolescent, age 16, is brought to the clinic for evaluation for a suspected eating disorder. To best evaluate the effects of role and relationship patterns on the child's nutritional intake, the nurse should ask:

3. "Do you like yourself physically?"

A 15-year-old client comes to the clinic requesting a test for human immunodeficiency virus (HIV) exposure. The adolescent is concerned that her parents might be notified of her test results. Which response by the nurse is best?

3. "HIV testing is confidential; after we get the test results we'll discuss your options."

To establish a good interview relationship with an adolescent, which of the following strategies is most appropriate?

3. Asking open-ended questions

How should the nurse proceed when discussing safe sexual practices with an adolescent?

3. Assess the adolescent's level of knowledge and concerns.

The nurse is teaching a group of adolescents about safety. Which safety topic takes priority in this age-group?

3. Automobile safety

The nurse is teaching a group of adolescents about automobile safety. Which is the most effective teaching method for this age-group?

3. Coordinating a panel of peers who were involved in motor vehicle accidents

The nurse is assigned to an adolescent. Which nursing diagnosis is most appropriate for a hospitalized adolescent?

3. Fear related to disturbed body image

The nursing staff is developing a care plan for a client who's receiving palliative care for end-stage leukemia. The client is experiencing break-through pain, which she rates as 5 on a 1 to 10 pain scale. Which action by the nurse should be included in the client's care plan?

1. Meeting with the pain management team to devise a more effective pain control plan

A girl, age 15, is 7 months pregnant. When teaching parenting skills to an adolescent, the nurse knows that which teaching strategy is most effective?

1. Providing a one-on-one demonstration and requesting a return demonstration, using a live infant model

A nurse brings gifts and flirts with a 16-year-old male client who's undergoing rehabilitation after sustaining a spinal cord injury that left him paralyzed below the waist. When a coworker confronts the nurse, the nurse replies, "He knows it's just in fun." How should the coworker handle this ethical dilemma?

1. Report the situation to the nursing supervisor.

The physician prescribes penicillin potassium oral suspension 56 mg/kg/day in four divided doses for a client with anorexia nervosa who weighs 25 kg. The medication dispensed by the pharmacy contains a dosage strength of 125 mg/5 ml. How many milliliters of solution should the nurse administer with each dose?

14

The parents of an adolescent girl have recently learned that their daughter has a terminal illness. At first, as they try to cope, they display avoidance behaviors. Then they demonstrate behaviors that indicate possible acceptance of the diagnosis. Which of the following behaviors would indicate acceptance?

3. Expression of feelings, such as sorrow and anger, about the child's condition

An adolescent is diagnosed with iron deficiency anemia. After emphasizing the importance of consuming dietary iron, the nurse asks the child to select iron-rich breakfast items from a sample menu. Which selection demonstrates knowledge of dietary iron sources?

3. Ham and eggs

A tuberculosis intradermal skin test to detect tuberculosis infection is given to a high-risk adolescent. How long after the test is administered should the results be evaluated?

3. In 48 to 72 hours

According to Erikson, the psychosocial task of adolescence is the development of a sense of identity. The nurse can best promote the development of a hospitalized adolescent by:

4. encouraging peer visitation.

An adolescent who's newly diagnosed with type 1 diabetes provides a return demonstration of self-insulin administration. Which action by the client demonstrates proper disposal of the insulin syringe?

3. Placing the syringe with the uncapped needle in the designated puncture-resistant container

Which of the following immunizations should an adolescent, age 12, receive as a component of preventative care?

3. Tetanus and diphtheria toxoids