Passpoint Adolescent

An adolescent is brought to the emergency department in a coma and is diagnosed with diabetic ketoacidosis. What is the correct action for the nurse to take?

Infuse intravenous fluids as prescribed.

An adolescent client is sent to the school clinic with dizziness and nausea. While assessing the student, who denies any health problems, the nurse smells alcohol on their breath. Which response by the nurse is most appropriate?

"Tell me everything that you have had to eat and drink yesterday and today."

An adolescent with pneumonia shares fears of having contracted human immunodeficiency virus (HIV). The adolescent wants to be tested but does not want parental involvement. What should the nurse say?

"The healthcare provider will run the test confidentially."

A nurse is caring for an adolescent after surgery. Which post-operative teaching statement is best to use for the adolescent?

"The instructions that I give you will help you get back to your regular activities quickly."

A nurse, who witnesses an adolescent being thrown from a motorcycle, stops to help. The adolescent reports that they are unable to move their legs. While waiting for the emergency medical service to arrive, what should the nurse do?

Leave the adolescent as they are, staying close by.

The nurse discovers that an adolescent client with anorexia nervosa is taking diet pills rather than complying with the diet. What should the nurse do first?

Listen to the client discuss fears of losing control of eating while being treated.

An adolescent presents with a large round ring with a swollen border on the left arm. The adolescent often plays ball games in a field behind the school. What condition does the nurse suspect?

Lyme disease

An adolescent is at risk for injury related to intracranial pathology following a motor vehicle collision. Which nursing action is the priority?

Monitor intracranial pressure.

A 13-year-old girl is being evaluated for possible Crohn's disease. She is about to undergo a colonoscopy with biopsy. While teaching about the diagnosis, the nurse is asked whether the client's delayed puberty is a result of the disease process. Which is the nurse's best response?

"No definitive diagnosis has been made yet; it's best to wait until testing is complete."

The parent of a 16-year-old adolescent calls the emergency department, suspecting the adolescent's abdominal pain may be appendicitis. In addition to pain, the adolescent has a temperature of 100°F (37.7°C) and has vomited twice. What should the nurse tell the parent?

"Bring your child into the emergency department immediately before the appendix has a chance to rupture."

A 15-year-old adolescent confides in the nurse that the adolescent has been contemplating suicide. The adolescent has developed a specific plan to carry it out and pleads with the nurse not to tell anyone. What is the nurse's best response?

"For your protection, I can't keep this secret. After I notify the physician, we will need to involve your family. We want you to be safe."

A nurse is approached by an adolescent who has been admitted to the hospital for headaches. The client confides that they are being sexually abused by a family friend. What should be the nurse's best initial response?

"I believe you; you were right to tell me."

An adolescent is receiving chemotherapy for lymphoma. Which statement by the adolescent supports a nursing diagnosis of Deficient knowledge related to mouth care?

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

The parent of an adolescent girl with Down syndrome tells the nurse that their daughter recently stated that they have a boyfriend. The parent is concerned that their daughter might become pregnant. Which is the most appropriate suggestion made by the nurse?

"I understand your concern; you may want to start your child on long-acting contraception."

Which statement by an adolescent receiving gentamicin should the nurse interpret as indicating drug toxicity?

"I'm feeling dizzy."

A nurse is performing a psychosocial assessment on a 14-year-old adolescent. Which response to the assessment questions is not typical during early adolescence?

"I'm sorry for how I acted earlier. Let's finish these questions."

A 12-year-old client says, "Give me my pajamas. I'm not putting your silly gown on." What is the most appropriate response by the nurse?

"You're upset because you feel awkward and embarrassed in these gowns."

An adolescent sustains a head injury and develops diabetes insipidus. The healthcare provider orders desmopressin, 10 mcg subcutaneously. When does the nurse assess the client to determine the need for an additional dose?

4 to 7 hours

A nurse teaches an adolescent client with asthma to independently administer breathing treatments. Which principle should the nurse keep in mind when planning the teaching session?

Adolescents are worried about appearing different from their peers.

A 19-year-old nulligravid client visiting the clinic for a routine examination asks the nurse about cervical mucus changes that occur during the menstrual cycle. Which information would the nurse expect to include in the client's teaching plan?

As ovulation approaches, cervical mucus becomes clear and stretchy.

The nurse is developing a care plan for a female child who is 12 years of age and receiving surgery to correct idiopathic scoliosis. Which postoperative problem is a priority?

pain control

During assessment of an adolescent who has sustained a recent thoracic spinal injury, the nurse auscultates the adolescent's abdomen. The nurse explains to the parents that this is necessary because clients with spinal cord injury often develop which problem?

paralytic ileus

An adolescent is a heavy user of marijuana and alcohol. When the nurse confronts the client about their drug and alcohol use, they admit previous heavy use in order to feel more comfortable around peers and achieve social acceptance. They acknowledge trying to stay clean since their parents found out and had them seek treatment. When the nurse develops a plan of care with the client, what should be the highest priority to help them maintain sobriety?

peer recognition that does not involve substance use

A nurse is caring for an adolescent who is in the hospital for a long-term illness. Which of the following interventions would promote the development of the hospitalized adolescent?

Connect the teen to their peer group as much as possible

An adolescent at a mental health clinic tells the nurse about feeling an overwhelming sadness and isolation for several months. The adolescent states a lack of interest in school and family life and proclaims, "No one cares about me. I wish I were dead." Which information would be most important for the nurse to obtain in order to plan appropriate care?

Determine whether the adolescent has developed a plan for committing suicide.

The nurse is caring for an adolescent with cancer who is well informed about the medical condition and treatment. The adolescent refused the morning medications and states intentions of refusing all future medications. What is the best action by the nurse?

Document the adolescent's choice and offer to discuss feelings about the medication.

An adolescent tells the nurse that they would like to use tampons during their period. What should the nurse do first?

Provide information about preventing toxic shock syndrome.

An adolescent presents to a community clinic for treatment of vulvar lesions associated with Type 2 herpes simplex. Which action does the nurse take?

Show the adolescent to a private examination room for further assessment.

A nurse is caring for a 16-year-old male client who needs an appendectomy. His parents are not present at the hospital. Prior to the surgery, the nurse needs to ensure that informed consent is obtained. Which situations allows the healthcare provider to obtain an informed consent from an adolescent?

The adolescent has declared himself emancipated.

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

administering multiple doses of insulin

A nurse is preparing a health promotion program for teenagers focusing on lifestyle choices. Which of the following methods used by the nurse will best ensure the success of the program?

creating a safe environment for sharing information

An adolescent with well-controlled type 1 diabetes has assumed complete management of the disease and wants to participate in gymnastics after school. To ensure safe participation, the nurse should instruct the client to adjust the therapeutic regimen by:

eating a snack before each gymnastics practice.

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

fear related to altered body image

The nurse is instructing a client with cancer who is receiving chemotherapy about reporting signs of infection. Which is the most reliable early indicator of infection in a client who is neutropenic?

fever

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

ham and eggs

Which finding should lead the nurse to decide that spinal shock was resolving in the adolescent with a spinal cord injury?

hyperactive reflexes

A 14-year-old 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?

identity

After 6 months of treatment with diet and exercise, an adolescent with type 2 diabetes still has a fasting blood glucose level of 140 mg/dL (7.8 mmol/L). The health care provider (HCP) has decided to begin metformin. The client asks how the medication works. The nurse should tell the client that the medicine decreases the glucose production and performs which other function?

increases insulin sensitivity

The nurse assesses an adolescent client with lethargy, retractions of the intercostal spaces, a persistent expiratory wheeze, diminished breath sounds, tachycardia, and tachypnea. Arterial blood gas results are pH 7.10; PCO2 80 mm Hg (10.64 kPa); PO2 35 mm Hg (4.66 kPa), HCO3 29 mEq/l (29 mmol/l). What is the priority condition the nurse must address?

respiratory acidosis

An adolescent 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 should be the priority assessment?

respiratory system

When assessing a 13-year-old adolescent, what is an expected finding?

subjective judgments of right and wrong

An adolescent with a history of surgical repair for an undescended testis comes to the clinic for a sports physical. Which anticipatory guidance for the parents and adolescent is most important?

technique for monthly testicular self-examinations

A school nurse interviews the parent of a middle school student who is exhibiting behavioral problems, including substance abuse, following a sibling's suicide. The parent says "I'm a single parent who has to work hard to support my family, and now I've lost one child and my other child is acting out and making me crazy! I just can't take all this stress!" Which concern regarding this family has top priority at this time?

the potential suicidal thoughts/plans of both family members

The nurse is preparing a teaching plan for a 14-year-old child who is newly diagnosed with asthma. Which content should be taught first?

when to seek immediate medical attention

The school nurse is counseling a female client who is concerned about an incident that occurred at a school dance. The young client describes becoming drowsy and disoriented after drinking punch and waking up hours later in the back of a stranger's car. What is the most appropriate advice for the nurse to give the adolescent?

"It's possible that you were raped and will need information on pregnancy testing."

An adolescent female client suspects that they might have polycystic ovarian syndrome (PCOS). Which symptom(s) would be consistent with PCOS? Select all that apply.

-obesity -increased body hair -acne -darkened skin in body fold

The nurse is teaching an adolescent with celiac disease about dietary changes that will help maintain a healthy lifestyle. Which of the following foods can the nurse safely recommend as part of the adolescent's diet? Select all that apply.

-potatoes -apples -corn

The nurses discusses the onset of pubescence with parents. The nurse should explain that pubescence occurs at what time?

1 to 2 years earlier in girls than in boys

When developing the teaching plan for an adolescent with insulin-dependent diabetes, the nurse should include what information about the relationship between exercise, diet, and insulin?

"If your blood glucose is very elevated, don't run."

An adolescent client who has been taking an antidepressant for 6 weeks has returned to the clinic for a medication check. When the nurse talks with the client and their parent, the parent reports that they have to remind the client to take the antidepressant every day. The client says, "Yeah, I'm pretty bad about remembering to take my meds, but I never miss a dose because my parent always bugs me about taking it." Which response would be effective for the nurse to make to the client?

"It seems there are some difficulties with being responsible for your medications that we need to address."

A member of a nurse-led group for depressed adolescents tells the group that they are not coming back because they are taking medication and no longer need to talk about their problems. Which response by the nurse is most appropriate?

"The purpose of the group is to provide each of you with a place to discuss the problems of being a teenager with depression with others who also are experiencing a similar situation."

The nurse is caring for an adolescent client after an overdose on barbiturate drugs and alcohol. The client is hypotensive with a mean arterial pressure below 30 mm Hg and a urine output of 5 mL/hr. Serum creatinine and potassium are elevated. The parents of the client ask why there is so little urine in the indwelling catheter drainage bag. What is the best response by the nurse?

"There is not enough blood circulating to the kidneys."

The parents of an adolescent client newly diagnosed with anorexia nervosa are meeting with the nurse during the admission process. Which remark should the nurse interpret as typical for parents of a client with anorexia nervosa?

"They've been a model child. We've never had any problems with them."

A 17-year-old adolescent with acute lymphocytic leukemia is discharged with written information about chemotherapy administration and an outpatient appointment schedule. The client 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 care plan?

letting the adolescent participate in planning and scheduling of treatments

An athletic teenager who is diagnosed with infectious mononucleosis is told to avoid contact sports for 3 to 4 weeks. The teenager protests to the nurse and demands to know why sports must be avoided for so long. What is the best response by the nurse?

"Your spleen is enlarged from your illness and could easily rupture with an injury."

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

-increased hormone levels -growth of anaerobic bacteria

A nurse is assessing the growth and development of a 14-year-old boy. The client reports that their 13-year-old sister is 2 inches (5 cm) taller than them. What information should the nurse provide about growth spurts in adolescent boys compared with growth spurts in adolescent girls?

about 2 years later.

A 15-year-old client with a BMI of 20 three months ago has lost 30 lb (13.6 kg) since then. What other finding is the nurse likely to assess?

amenorrhea

Acetaminophen was given to an adolescent for headache. Which of the following parameters would indicate the effectiveness of the medication?

change in behavior

A nurse is caring for an adolescent involved in a motor vehicle crash. The adolescent has a chest tube in place. If the chest tube is accidentally removed, the nurse should immediately:

cover the opening with petroleum gauze.

Physical examination of an adolescent reveals an abnormally convex angulation in the curvature of the thoracic spine. How should the nurse document this finding?

kyphosis

The nurse is caring for a 15-year-old adolescent mother after birth. The adolescent lives at home with her parents and has a boyfriend who is also 15 years old. Neither is currently working, and they both have plans for higher education. When addressing the psychosocial issues that may occur after the birth of the child, which of the following would be the most important for the nurse to include in client teaching?

increased stress for new mothers

The nurse cares for an adolescent after an appendectomy. Which client action would the nurse judge to be a healthy coping behavior?

insisting on wearing a T-shirt and gym shorts rather than pajamas

The nurse assesses a teenage girl's musculoskeletal system (see figure). What finding should the nurse document?

lordosis

A 14-year-old brought to the emergency department with right lower quadrant pain is tentatively diagnosed with acute appendicitis. The nurse should further assess the client for which sign or symptom?

low-grade fever

An adolescent is admitted for treatment of bulimia nervosa. When developing the care plan, the nurse anticipates including interventions that address which metabolic disorder?

metabolic alkalosis

An adolescent child is admitted to the nursing unit after an attempted suicide. The nurse is discussing the attempted suicide with the parents. Which of the following statements by the parents indicate to the nurse that the parents need more teaching? Select all that apply.

-"Our child is just trying to get attention." -"Our child would not do this again." -"Our child will be fine in a couple of days."

Client is a 13-year-old who presented to the emergency department after suffering a sports related injury. Client's left forearm is significantly larger than left due to swelling and tissue damage. Bone is protruding through skin with bleeding. Capillary refill: 1 second in affected extremity. Client rates pain as a 10 (1 = no pain, 10 = worst pain). Which nursing interventions are appropriate for this client?

-Administer analgesics -Elevate affected limb -Apply direct pressure to wound -Administer fluid replacement -Apply a sterile wound dressing -Educate on possible need for tetanus prophylaxis

An adolescent presents to a community clinic for treatment of vulvar lesions associated with type 2 herpes simplex. Which intervention is appropriate to do at this time? Select all that apply.

-Escort the adolescent to a private examination room. -Provide the adolescent with literature about type 2 herpes simplex.

A school nurse is planning a program for parents on "Drugs Commonly Abused by Teenagers." Which information should be included about inhalants? Select all that apply.

-Monitor for paper bags and rags that may have been used for breathing inhalants. -Deaths from inhalants occur from asphyxiation, suffocation, and aspiration of vomit. -Inhalants usually cause depression of the central nervous system. -The basic groups of inhalants are hydrocarbon solvents such as glue, aerosol propellants from spray cans, and anesthetics and gases.

A student with type 1 diabetes tells the nurse they are feeling light-headed. The student's blood sugar is 60 mg/dL (3.3 mmol/L). Using the 15-15 rule, the nurse should perform which action to treat the blood glucose?

15 g of carbohydrate, and retest the blood sugar in 15 minutes.

A nurse is caring for a 14-year-old adolescent who states, "No one understands me." Which statement by the nurse best demonstrates empathy?

"It's difficult to be a teenager. Tell me more about your experiences."

A nurse is providing health teaching to a group of adolescent females. The focus is on urinary tract infections. One of the adolescents tells the nurse that she wants to know what cystitis is. Which statement by the nurse is the most appropriate response?

"This condition can result from irritation and inflammation from sexual activity."

The nurse is providing health screening for adolescent girls. Which of the following adolescent girls does the nurse identify as highest risk for an unplanned pregnancy? Select all that apply.

-an adolescent girl living in poverty -an adolescent girl with low self-esteem -an adolescent girl with low educational achievement -an adolescent girl dating an older boy

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

-hypercholesterolemia -hypoproteinemia -proteinuria -periorbital edema

An adolescent is being seen in the clinic for abdominal pain with a fever. In what order should the nurse assess the abdomen? All options must be used.

-inspect -auscultate -percuss -palpate

A 16-year-old client is admitted to the emergency department following an accident. The client sustained a head injury, is unconscious, and has compound fractures of the right tibia and fibula. No family members accompanied the client and none can be reached by phone. The surgeon instructs the nurse to take the client to the operating room immediately. Which of the following actions should the nurse take regarding informed consent?

Take the client to the operating room for surgery without informed consent.

The nurse is assessing an adolescent 1 hour after admission for a head injury. The nurse identifies that there have been changes since the baseline assessment, including apnea, bradycardia, and a widening pulse pressure. What is the primary reason for the nurse to notify the healthcare provider?

The changes suggest that the client's intracranial pressure is increasing.

The nurse talks to an adolescent about how they can tell their friends about their new diagnosis of diabetes. Which behavior by the adolescent indicates that the adolescent has responded positively to the discussion?

The client introduces the nurse to their friends as "the one who taught me all about my diabetes."

When teaching an adolescent about measures to improve facial acne, the nurse should give the client what instructions about skin care?

Wash the face twice a day with mild soap and water.

The charge nurse on the adolescent unit must decide which nurse should admit a new client. Based on the present client care assignments, who is the best candidate to admit the client?

a nurse who was reassigned from another ward at the beginning of the shift

The nurse is caring for an adolescent who has been admitted several times with uncontrolled type 1 diabetes. The child is now stabilized and is preparing for discharge. What should be the priority focus for the nurse when conducting discharge teaching?

management of the therapeutic regimen

The nurse is providing an education program to a group of adolescents on the importance of testicular self-examinations. One of the participants asks the nurse, "when is the best time to do the examination?" What is the best response by the nurse?

when you are in the shower or immediately after

A 17-year-old client confides in the school nurse an interest in understanding safe sex practices. In instructing the client on how to correctly use a condom, which information would be stressed? Select all that apply.

-Condoms should be stored in a cool, dry place to prevent damage. -Leave a 1/2-inch space at the tip of the condom. -Never reuse a condom. -The condom should be applied on an erect penis.

An adolescent client who is being seen by the crisis nurse after making several superficial cuts on their wrist states that all their friends are siding with their ex-partner and will not talk to the client anymore. The client says that although they know the relationship is over, "If I can't have my ex, no one else will." Which client problem takes the highest priority?

risk for other-directed violence

When developing the postoperative plan of care for an adolescent who has undergone an appendectomy for a ruptured appendix, the nurse should expect to place the client in which position during the early postoperative period?

semi-Fowler

A nurse has been caring for an adolescent client in a residential facility. The child has been through a series of foster placements since infancy with no success in any placement until the age of 7 when placed with a middle-age single woman. The client thrived there until the woman was killed in a car accident. The client attempted suicide after their foster parent died and was subsequently placed in the residential facility. The nurse has become close to this client and wants to help them address their issues and move on with their life. Which comment to the manager demonstrates that the nurse understands the client's issues and is able to respond appropriately to the client's needs?

"It's difficult for the client to love and trust again after their losses. In this facility, they can learn to deal with their loss in a less emotionally charged environment than a foster home."