Peds Ex 2 Ch 29
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?"
During the assessment of a 15-year-old female, the nurse notes a new body piercing in the navel. Which statements by the nurse would be appropriate in regard to this new piercing? Select all that apply.
"I notice you have a new piercing. Be sure to clean it twice a day so you don't get an infection." "Did they tell you when you got your piercing how important cleaning it is? Infections can take up to a year to heal in a naval piercing."
The nurse is discussing an adolescent's development with the client's parents. Which statement by the parents indicate an understanding of the nurse's teaching?
"Our adolescent is working toward achieving a sense of personal identity."
A 15-year-old female adolescent tells the nurse she would like to get a tattoo. What response by the nurse is most appropriate?
"Tattoos are invasive and there is the potential for disease with their application."
An adolescent who is depressed states, "Nothing ever seems to be right in my life." Which would be the most appropriate response by the nurse?
"You are feeling sad right now. It's a hard time."
The nurse is assessing a 14-year-old male client when the client's parent jokes about the changes in the client's voice and the hair under his armpits. Which response by the nurse to the client's parent is most appropriate?
"Your child can become modest and self-conscious and teasing may cause embarrassment."
A 17-year-old female is meeting with the nurse for an annual well-visit and is asking the nurse questions about how to know when one is in love. The nurse should point out which factor to help decide if both individuals have reached a mutual agreement and are ready for an intimate relationship?
A sense of trust and identity
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
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?
Assess the client for signs of infection.
The nurse is preparing to participate in a community discussion on the needs of the adolescents in the local school. The nurse should point out which goal is the primary concern for these young individuals as the committee makes plans?
Teens are busy developing their own personal identity.
The father of a 15-year-old daughter is concerned she is not getting adequate nutrition to play high school basketball. Her games are on Friday nights. Which suggestion should the nurse point out will best suit the needs of this adolescent?
Three daily meals that include choices from each of the food groups; Friday's lunch eaten around 2 p.m. with a small amount of fat and a somewhat larger than usual portion of complex carbohydrates.
The nurse is working with a 12-year-old who has recently experienced family instability and family violence. When assessing this client in the context of Erikson's developmental theory, the nurse should recognize that the adolescent has a risk of which negative outcome?
confusion about role in the world
The nurse is talking to a 13-year-old boy about choosing friends. Which function do peer groups provide that can have a negative result?
following role models
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.
A male nurse is meeting with a group of 12-year-old boys to discuss expected bodily changes. After one of the boy's says, "My older brother told me my bed might be wet and that means I had a wet dream. Is that true?" What is the best response from the nurse?
"Having wet dreams indicates that your body is going through a process of maturing."
The nurse is counseling an overweight, sedentary 15-year-old girl. The nurse is assisting her to make appropriate menu choices. Which statement indicates the adolescent understands how to make appropriate dietary selections?
"I need to eat plenty of fruit each day."
The mother of a 9-year-old female voices concern to the nurse about her daughter developing breasts "at such a young age." How should the nurse respond?
"I understand your concern, but girls typically enter puberty around the age of 9 or 10."
The nurse is providing anticipatory guidance to the parents of a 15-year-old who voice concerns with their teenager's sleep habits. They state, "Left to her own devices, I'm sure she'd stay up until 3:00 in the morning on the weekends and sleep until after lunchtime." Which should the nurse explain to the parents?
"That must be hard for you to manage. Perhaps we can explore some strategies with her to establish more predictable sleep patterns."
A nurse is explaining cognitive development in children to a client, with the help of Piaget's theory of cognitive development. What would be the best explanation by the nurse about the formal operations level of cognitive development?
After age 12 children can think in the abstract, including complex problem solving.
A 15-year-old is hospitalized for acute appendicitis. Which activities would the nurse include in the client's plan of care? Select all that apply.
Allow friends to visit during visiting hours. Include the parents when educating the client. Arrange care to provide for extra rest and sleep.
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?
Allow the adolescent to choose the time for the dressing change.
A nurse is attending to a group of boys at a school. The nurse is required to document the sexual development in boys on a regular basis. The nurse would anticipate which clients having the highest incidence of nocturnal emissions?
Clients who are showing pubertal changes
To help prevent obesity, which intervention would the nurse include in an adolescent's plan of care?
Describe a normal serving size.
A nurse is taking care of a teenager who reports involuntary discharge of semen while sleeping. The nurse observes that the client is confused and does not know about the pubertal changes that are taking place in his body. Based on this information, what is the highest priority area that should be reviewed with the client?
Educate the client about the changes that occur during adolescence.
The parents of a 16-year-old male are worried about recent changes in his behavior, ignoring his schoolwork and sports, and spending almost all of his free time interacting with his girlfriend. Which suggestion should the nurse point out would best address this situation?
He has developed his own identity by now; being able to establish close relationships with girls is important preparation for all of his adult relationships. They should honor his need to be with, or talk to, his girlfriend as long as he has completed his schoolwork for the day.
The school nurse is developing a school wellness program to promote healthy eating habits and regular physical activity. What is the most important element to emphasize to maximize compliance, healthy habits, and long-term change?
Include both parents and children in the wellness program.
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?
Provide reassurance that these are normal changes.
A 16-year-old client has been hospitalized 100 miles from home for 1 week to repair a fractured patella suffered in a skateboarding accident. She was cheerful and chatty when she first arrived, but the nurse notes in recent days she has become increasingly quiet and seems lonely. Which nursing intervention should the nurse prioritize for this client?
Take her to the teen lounge so she can meet and interact with other teens.
The nurse is educating a 17-year-old adolescent after a new diagnosis of diabetes. What does the nurse understand about teaching an adolescent?
The adolescent will likely have the greatest influence on one's own decisions.
While assessing a 17-year-old client, the nurse notes the following: blood pressure 152/96 mm Hg, pulse 124 beats/minute, respirations 20 breaths/minute, temperature 98.8°F (37.1°C), dilated pupils, euphoric state, and pressured speech. Which intervention would the nurse anticipate the health care provider to prescribe first?
Urine drug screen
A 15-year-old adolescent is seen at a health care facility for facial acne. When counseling the teen, the nurse would teach that the basic cause of acne is:
activation of androgen hormones.
A teenage boy tells the nurse that his parents embarrass him in front of his friends when they kiss him goodbye. The nurse is aware that this teenager is revisiting which stage of development identified by Erikson?
autonomy
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 priorityassessment data does the nurse need?
heart rhythm
The nurse is promoting nutrition to a teen who is going through a growth spurt. Which food should the nurse recommended for its high iron content?
whole grain bread
A 16-year-old adolescent is talking with the nurse at a local health clinic about skin care. Which comments by the teen does the nurse determine require additional conversation? Select all that apply.
"I only tan before going on spring break to get a base tan so I won't burn." "My favorite time of day to be outside is the middle of the day, around noon." "The more exposure and burns I get now will toughen my skin so I won't get skin cancer when I'm older."
For reasons of anticipatory guidance, nurses should be aware that menarche appears earlier in some ethnic groups than others. In which ethnic group is menarche likely to appear first?
Black
The nurse is preparing a presentation for a local health fair depicting the differences in maturity between preadolescents. Which differing factor should the nurse prioritize in the presentation?
Boys grow at a slower, steadier rate than do girls.
The mother of a 13-year-old boy confides to the pediatric nurse practitioner that her son has recently had a nocturnal seminal emission. The mother is concerned, and the nurse explains "wet dreams" and the other male traits of puberty to the mother. Which response indicates a need for further discussion?
"My son must be sexually active or having overly sexual thoughts to have a nocturnal emission."
