Passpoint - Adolescent
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?
"About 4 to 7 years."
A 14-year-old with type 1 diabetes is admitted with ketoacidosis for the second time in 3 months. The parent states, "I don't know why this keeps happening." Which response by the nurse is best?
"Adolescents sometimes become overwhelmed by adhering to dietary restrictions and taking medications."
The nurse is caring for a 14-year-old with type 1 diabetes who has been admitted with ketoacidosis for the second time in 3 months. The parent states, "I don't know why this keeps happening." Which response by the nurse is the most appropriate?
"Adolescents sometimes become overwhelmed by having to adhere to dietary restrictions and taking medications."
The nurse is collecting data from an adolescent with pelvic inflammatory disease (PID). What symptoms are anticipated when reviewing data?
lower abdominal pain and urinary tract symptoms
The nurse is teaching a group of adolescent girls about personal hygiene. Which statement by an adolescent indicates the need for further teaching?
"It's unsafe to bathe during your period."
After a nurse reinforces education with an adolescent about syphilis, which statement by the adolescent indicates the need for further education?
"Syphilis is rarely transmitted sexually."
A 15-year-old girl visits the neighborhood clinic seeking information on how to prevent pregnancy. How should the nurse respond to her request?
"What precautions are you taking now when you have sex?"
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:
"Do you like yourself physically?"
A nurse is caring for a 16-year-old female who is sexually active. The nurse is reinforcing education with the client about preventing sexually transmitted infections (STIs). What statement by the adolescent indicates a need for further instruction?
"I am protected from contracting HIV and other STDs because I am on oral contraceptives.
A nurse is conducting a health class at the local middle school about testicular self-examination. What statement by a student would indicate a need for further teaching?
"I do not need to perform testicular self-exams until I become sexually active."
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?
"I remove white patches on my tongue and cheeks with my toothbrush."
A nurse determines that an adolescent with a fractured left femur understands the instructions to perform only touch-down weight bearing when making what statement?
"I will allow my left leg to touch the floor without placing weight on it."
The parent of a 16-year-old child calls the emergency department, suspecting their child's abdominal pain may be appendicitis. In addition to pain, the child has a fever of 100° F (37.8° C) and has vomited twice. What would be appropriate advice for the nurse to give the parent?
"Immediately bring your child into the emergency department."
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?
"This abuse can't be kept secret; let's devise a safety plan. Do you have an adult you can turn to?"
The nurse is reinforcing education to an adolescent about sexually transmitted infection (STI). What statement made by the client indicates that further education is required?
"You always know when you have gonorrhea."
At what age should boys be taught how to do a monthly testicular self- examination?
12 years old
The nurse is caring for a 15-year-old client admitted with suspected bacterial pneumonia. Which nursing action takes priority?
Obtain a sputum culture.
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?
Providing small, frequent meals
A school nurse suspects that a 13-year-old has structural scoliosis. Asking the adolescent to perform which maneuver would be the nurse's priority when gathering data for this condition?
The child bends over and touches the toes while the nurse observes from behind.
A 13-year-old has received third-degree burns over 20% of the body. When observing this client 72 hours after the burn, which finding should the nurse expect?
increased urine output
The nurse is working with an adolescent female diagnosed with scoliosis. What problem is commonly encountered by this group?
poor self-esteem
An adolescent with diabetes tells the community nurse they recently started drinking alcohol on the weekends. Which action would be most appropriate for the nurse to take?
Educate the adolescent about the effects of alcohol on diabetes.
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?
Encouraging visitation by his friends
A 13-year-old visits the school nurse experiencing back pain, fatigue, and dyspnea. The nurse suspects that the child may have scoliosis. What is the nurse's first action?
Inspect the child for uneven shoulder height or uneven hip height.
The nurse is reinforcing education with an adolescent about gonorrhea. Which information should be included?
Treatment of sexual partners is an essential part of treatment.
A 14-year-old is seen in the pediatrician's office with a history of mild sore throat, low-grade fever, a diffuse maculopapular rash, and reports swelling of the wrists and redness in the eyes. The nurse interprets these findings as indications of which condition?
rubella
The nurse is teaching a group of adolescents about safety. Which safety topic takes priority in this age-group?
Automobile safety
A nurse is caring for an adolescent who underwent surgery for a perforated appendix. What should the nurse keep in mind regarding the main life-stage task for the adolescent when providing care?
Developing identity and independence is the objective.
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?
Placing the syringe with the uncapped needle in the designated puncture-resistant container
An adolescent with ulcerative colitis hasn't responded to nutritional intervention and drug therapy. During data collection, the nurse expects to note:
delayed sexual development
The nurse is providing anticipatory guidance to a 16-year-old female at her well checkup. Which topics would be included in the discussion? Select all that apply.
driving responsibilities protection from sexually transmitted infections anxiety related to career choices
An adolescent reports feet that itch, sweat a lot, and have a foul odor. The nurse suspects which condition?
tinea pedis
The nurse is teaching a group of adolescent girls about personal hygiene. Which statement by an adolescent indicates the need for further education?
"It's unsafe to bathe during your period."
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?
"What thought have you given as to how you'll manage school, babysitting, and your other responsibilities?"
The nurse is discussing safe sexual practices with an adolescent. What is the best way for the nurse to engage the adolescent?
Assess the adolescent's level of knowledge and concerns.
A 17-year-old client visits the family planning clinic to discuss with a nurse regarding safe sex practices. In instructing the client on how to correctly use a condom, which information should be stressed? Select all that apply.
Condoms should be stored in a cool, dry place to prevent damage. Leave a ½ inch space at the end of the condom. Never reuse a condom. The condom should be applied on an erect penis.
The nurse is teaching a group of adolescents about automobile safety. Which is the most effective teaching method for this age-group?
Coordinating a panel of peers who were involved in motor vehicle accidents
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?
Expression of feelings, such as sorrow and anger, about the child's condition
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?
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?
Letting the client participate in the planning and scheduling of treatments
The nursing staff is developing a care plan for a client who's receiving palliative care for end-stage leukemia. The client is experiencing breakthrough pain, rated as a 5 on a pain scale of 1 to 10. Which action by the nurse should be included in the client's care plan?
Meeting with the pain management team to devise a more effective pain control plan
The school nurse is discussing skin cancer prevention with a group of teenagers. When asked suggestions and how to decrease the incidence of skin cancer, which information will the nurse emphasize in the discussion? Select all that apply.
Protect skin with sunscreen. Examine skin once per month, looking for suspicious lesions or changes in moles.
A 14-year-old is admitted for sickle cell crisis. Which nursing intervention would be most important?
Provide adequate oxygenation, hydration, and pain management.
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?
Providing a one-on-one demonstration and requesting a return demonstration, using a live infant model
The nurse is working with a group of adolescents reviewing information regarding the human immunodeficiency virus (HIV). What fact is important for the nurse to include in the review?
The virus can be spread through many routes, including sexual contact.
A nurse is preparing a presentation to a group of female adolescents about pelvic inflammatory disease (PID). Which statement best reflects the focus of preventive education needs for this age group?
There are long-term complications related to reproductive tract infections.
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?
To help the nurse and client analyze the amount of food the client is eating and determine when food intake occurs
Which adolescent would the nurse consider at greater risk for developing acquired immunodeficiency syndrome (AIDS)?
a young, sexually active client with multiple partners
A nurse is teaching a 16-year-old female client with inflammatory bowel disease about corticosteroid treatment. Which adverse effects are likely to be concerns for this client? Select all that apply.
acne hirsutism mood swings osteoporosis Adrenal suppression.
A parent reports that their teenager is losing hair in small, round areas on the scalp. The nurse interprets this as suggesting which condition?
alopecia
The nurse is gathering data from an adolescent client. What technique is best to use when developing rapport?
asking open-ended questions
A nurse is interviewing a 16-year-old female at a clinic who reports that her boyfriend has exposed her to herpes. With primary genital herpes or herpes simplex type 2, what finding would the nurse expect to observe in the teen during the initial outbreak?
burning or tingling on the vulva, perineum, or vagina
The nurse is caring for an adolescent male diagnosed with Klinefelter syndrome. What will the nurse expect to see with the client with Klinefelter syndrome?
less facial and body hair small testes infertility
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:
cerebral edema.
A nurse is caring for a 16-year-old adolescent with aortic stenosis. Which finding is associated with aortic stenosis when the teen is active?
chest pain
A sexually active teenager seeks counseling from the school nurse about prevention of sexually transmitted infections (STIs). Which contraceptive measure should the nurse recommend?
condom and spermicide use
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:
cover the opening with sterile petroleum gauze.
The nurse is helping the adolescent deal with diabetes. What characteristic of adolescence should be considered?
need to be like peers
A nurse is caring for a 15-year-old who sustained a fracture of the femur 24 hours ago. Which finding should alert the nurse to an early complication?
dyspnea
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:
encouraging peer visitation.
When developing a plan of care for an adolescent, the nurse considers the child's psychosocial needs. During adolescence, psychosocial development focuses on:
establishing an identity.
The nurse is caring for an adolescent with syphilis. What factor must the nurse determine before the client can be treated?
existence of medication allergies
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
A 14-year-old client diagnosed 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 heredity
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:
the adolescent may feel isolated without the opportunity to develop relationships with the opposite sex.
The nurse is talking to an adolescent about preventing sport-related injuries. Which is the best strategy for the nurse to reinforce teaching about this subject?
warming up
An adolescent with diabetes is learning to mix regular insulin and NPH insulin in the same syringe. Which action, if performed by the teen, would indicate the need for further instruction?
withdraws the NPH insulin first
Which statement by a female adolescent reveals an early indicator of anorexia nervosa?
"I jog three times per day for a total of 5 hours per day."
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?
"HIV testing is confidential; after we get the test results we'll discuss your options."
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?
"Can you tell me about the precautions you're taking now?"
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?
"Whether or not you play football is your decision; tell us why you want to play."
A nurse is caring for a 14-year-old boy who arrives in the healthcare provider's office reporting abdominal pain with nausea and vomiting for the past 24 hours. The parent reports the client experiencing sharp pain when the car hit a pothole in the road. The vital signs are: temperature, 101.6°F (38.6°C); pulse, 92 beats/minute; respirations, 24 breaths/minute; blood pressure, 142/82 mm Hg. As the nurse is gathering data, in which location of the abdomen will the nurse obtain definitive data?
*** The X is placed in the right lower quadrant. All of the data provided (abdominal pain, nausea with vomiting, elevated temperature, and rebound tenderness when hitting a pothole) indicate a potential appendicitis. Appendicitis typically begins with anorexia, nausea, and vomiting for the first 12 to 24 hours. Abdominal pain, a late sign, is usually diffuse at first and gradually localizes to the right lower quadrant. The sharpest pain should be noted at McBurney's point, which is one-third of the way between the anterior and superior iliac crest and the umbilicus.
The health care provider 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? Record your answer using a whole number.
14
To establish a good interview relationship with an adolescent, which of the following strategies is most appropriate?
Asking open-ended questions
The nurse is planning sex and contraceptive education for adolescents. Which factor should the nurse consider?
Most teenagers are open about contraception, but inconsistently use birth control.
A nurse observes a gun under the jacket of a 17-year-old client's visitor. Which action should the nurse perform first?
Notify security immediately.
When planning a program to educate adolescents about acquired immunodeficiency syndrome (AIDS), which action might lead to better acceptance of the program?
Obtain peer educators to provide information about AIDS.
The school nurse is gathering data related to the diabetic status of a 15-year-old athlete. Which physiologic change should the nurse anticipate as a diabetic teenager becomes more physically active during the day?
increased need for food
A nurse is caring for a 17-year-old brought to the mental health facility by a family member who is concerned about the client's recent 20-lb (9 kg) weight loss, and weight loss total of 50 lb (22.7 kg) in the last year. What interventions are essential in the treatment of an adolescent diagnosed with an eating disorder? Select all that apply.
Provide a highly structured environment. Monitor the clients' weight, vitals, intake and output, caloric intake, and exercise. Assist the client in changing the negative perception to a positive one, and assist in setting realistic goals.
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?
Providing simple, straightforward, age-appropriate explanations about the procedure
Which of the following immunizations should an adolescent, age 12, receive as a component of preventative care?
Tetanus and diphtheria toxoids
The nurse is reinforcing education for a 17-year-old who'll be discharged on how to change a sterile dressing on the right leg. During the education session, the nurse observes redness, swelling, and induration at the wound site. What does this indicate to the nurse?
infection
When reviewing the chart of an adolescent admitted to the mental health unit, which indicators would the nurse expect to find that would indicate this client is a high risk for suicide? Select all that apply.
depression preoccupation with death previous suicide attempt
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:
inspect the child for uneven shoulder height or uneven hip height.
A 13-year-old with structural scoliosis has Cotrel-Dubousset rods inserted. Which position would be best during the post-operative period?
supine in bed
The nurse is caring for a 14-year-old child in skeletal traction for treatment of a fractured femur. The child is expected to be hospitalized for several weeks. When assisting with the plan of care, which nursing actions take into account the need to achieve developmental milestones in adolescence? Select all that apply.
Encourage visitation of friends during hospitalization. Provide for privacy, especially during ADLs and toileting. Arrange for in-hospital schooling so the child does not fall behind while hospitalized.
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?
Explaining that his sleep requirements have increased related to the increased metabolic demands of growth
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?
Ham and eggs
The nurse is caring for an adolescent, age 14. Which emotional response is typical during early adolescence?
Moodiness
The nurse is working with adolescents. Which developmental rationale explains risk-taking behavior?
Belief in their own invulnerability persuades adolescents that they can take risks safely.
A nurse is caring for an adolescent female with cystic fibrosis. Which statements about the course of cystic fibrosis are true? Select all that apply.
Breast development is commonly delayed. The client is at risk for developing diabetes. Normal sexual relationships can be expected.
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?
Completing a Medicaid application
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?
"Can you tell me your understanding of the implications of diagnostic testing and treatment?"
A nurse is reinforcing education about type 1 diabetes with an adolescent. Which instruction by the nurse about how to prevent hypoglycemia would be most appropriate for the adolescent?
"Carry crackers or fruit to eat before or during periods of increased activity."
A school nurse is planning a program on skin cancer prevention for a group of teenagers. Which instruction should the nurse emphasize during the program?
"Examine your skin once per month, looking for suspicious lesions or changes in moles."
An adolescent with type 1 diabetes mellitus is experiencing a growth spurt. Which treatment approach would be most effective for this client?
Administering multiple doses of insulin
A nurse is preparing to reinforce education with a 13-year-old child with asthma on how to administer breathing treatments. Which principle should the nurse keep in mind when planning the education session?
Adolescents are worried about appearing different from their peers.
The nurse is reinforcing education with an adolescent about metronidazole for the treatment of trichomoniasis. Which statement is important for the nurse to include in discharge education?
Alcohol should not be consumed.
How should the nurse proceed when discussing safe sexual practices with an adolescent?
Assess the adolescent's level of knowledge and concerns.
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?
Respiratory system
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:
develop an identity and independence.
The nurse is caring for a 14-year-old child in skeletal traction for treatment of a fractured femur. The child 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
