PP Adolescent
The nurse assesses a 17-year-old client with depression for suicide risk. Which question is most appropriate to use? "Can you tell me what you think about suicide?" "Has anyone in your family ever committed suicide?" "Are you thinking about killing yourself?" "What movies about death have you watched lately?"
"Are you thinking about killing yourself?" Explanation: Asking whether the client is thinking about killing themself is the most direct and therefore the best way to assess suicidal risk. Knowing whether the client has watched movies on suicide and death, what the client thinks about suicide, and whether other family members have committed suicide will not tell the nurse whether the client is thinking about committing suicide right now.
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? "If I sit through this whole appointment, what do I get out of it?" "I'm sorry for how I acted earlier. Let's finish these questions." "These questions are so stupid. When can I leave?" "I just want to go back to bed. When will this be done?"
"I'm sorry for how I acted earlier. Let's finish these questions." Explanation: Moodiness may occur often during early adolescence. Moodiness occurs due to immature cognitive control and emotional development. Essentially, early adolescent clients (age 10-14) have difficulty coping with emotions. These emotions are affected by the hormonal and maturing issues that occur during this time period. Anger and combativeness are more typical of middle adolescence. Cooperativeness typically occurs during late adolescence. Indications of depression are taken seriously and are not attributed to moody behaviors or statements
The parents of a pregnant adolescent are outraged that they are being refused medical information about their daughter's condition. What is the best response by the nurse to address their anger? "I understand your concerns, but she is responsible for her own health." "Your daughter is not ready to share her health information." "If we obtain permission from her, we can include you in our discussions." "Your daughter's medical information is confidential."
"If we obtain permission from her, we can include you in our discussions." Explanation: The reality of this situation is that the parents may be included in the exchange of medical information but only with the daughter's consent. Sharing that fact with the parents clearly identifies that the decision is the daughter's to make and that she is entitled to make it. The nurse must support the client's right to privacy and confidentiality. The client is responsible for her own health, and her information is confidential, but stating these facts does not adequately address the parents' concern. The client may not be ready to share any information, but this does not help the parents understand what is occurring. It is best to simply explain that the client's permission is necessary in order to include the parents in the sharing of medical information.
A nurse is caring for a 14-year-old adolescent who states, "No one understands me." Which statement by the nurse best demonstrates empathy? "Explain why you think no one understands you. How can adults help?" "Let's talk about your future plans and which courses you enjoy." "It's difficult to be a teenager. Tell me more about your experiences." "Tell me about a time you felt your parents were understanding."
"It's difficult to be a teenager. Tell me more about your experiences." Explanation: Empathy is the ability to put oneself in another's place and experience a feeling as that person is experiencing it. The correct answer acknowledges the adolescent's feelings and conveys an understanding without intimidating the client. Asking how adults can help and reflecting on parental understanding or favorite coursework is helpful overall but does not demonstrate empathy for the client.
A new client has just been admitted to an adolescent psychiatric inpatient unit. The charge nurse and an unlicensed assistive personnel (UAP) are discussing the client's needs. The UAP says, "They're just showing off to try and get our sympathy. There is no need for the client to cut themself. Why would adolescents want to do such a thing to themselves?" What response by the charge nurse is most indicated? "Working with adolescents can be extremely difficult at times. Would you prefer that I change your assignment? "You don't understand their problems and don't take them seriously, so you shouldn't be allowed to work with them during this hospitalization." "It's hard to see a young person harm themself as they do, but they have serious family issues and don't know better ways to handle them, so we have to help them with that."
"It's hard to see a young person harm themself as they do, but they have serious family issues and don't know better ways to handle them, so we have to help them with that." Explanation: The UAP is concerned about the behavior of the client and confused about why it is occurring, so the nurse needs to explain a bit about the issues involved as well as demonstrate empathy for the aide. It is appropriate to explain that the client is not cutting for attention, but the nurse's response does not address the reason for the teen's behavior and is therefore inadequate. It could also appear that the nurse is denigrating the UAP, which will not encourage the aide to listen to what the nurse has to say. The comments that the UAP cannot work with the client are punitive. Asking the UAP if they want their assignment changed does nothing to help the UAP understand self-mutilation and sets a bad precedent that the UAP can pick and choose an assignment.
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? "She is too young to be diagnosed with delayed puberty." "No definitive diagnosis has been made yet; it's best to wait until testing is complete." "Yes, Crohn's disease often causes delayed puberty." "You'll have to ask the doctor."
"No definitive diagnosis has been made yet; it's best to wait until testing is complete." Explanation: Although Crohn's disease may cause growth failure or delayed puberty, the client has not actually been diagnosed with anything yet; therefore, it cannot be said definitively that Crohn's is the culprit, if indeed puberty is delayed. Median age for menarche in the United States is 10.4 years; secondary sex characteristics should precede or follow within a few months. If Crohn's is diagnosed, other appropriate testing can follow if indicated.
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? 30 minutes to 2 hours 2 to 4 hours 15 to 30 minutes 4 to 7 hours
4 to 7 hours Explanation: The minimum required dose is given to avoid water retention and hyponatremia. Control of polyuria and electrolytes is the goal. Another dose is not administered until the client has another episode of brisk polyuria and diuresis, indicating the initial dose is no longer effective. The drug's half life via this route is 3 hours, indicating the drug will stop working in about 6 hours.
A 15-year-old with acute lymphocytic leukemia has been caught hiding her oral chemotherapy each morning. Which nursing intervention will improve compliance? Have the child meet teenage survivors of cancer who were compliant with treatment. Notify the physician to talk to the teenager and the family about compliance. Give written and internet resources of information about the disease process and implications of noncompliance. Discuss the noncompliance with the parents, child, and physician, setting limits and taking away privileges until the child complies.
Have the child meet teenage survivors of cancer who were compliant with treatment. Explanation: Have the teenager talk to other teenagers who are going through similar experiences. Talking to age-appropriate peers will make a bigger impact than trying to force the teenager to conform.
The nurse prepares to teach an adolescent scheduled for an appendectomy about what to expect. The adolescent says, "I would rather look this up on the internet." What should the nurse do? Explain that completing a teaching checklist is required by the hospital. Help the client find information on the internet. Provide the client with written information instead. Explain that information found on the internet cannot be trusted.
Help the client find information on the internet. Explanation: Part of providing client-centered care is to honor the client's preferred method of learning. The nurse should help the adolescent find accurate information about the procedure. By assisting with the information search, the nurse can verify learning. Teaching straight from a checklist does not encourage customization. If the client has requested to use the internet, it is unlikely that written information will be read. While it is true that some information on the internet is not accurate, the nurse can take this opportunity to help the client learn how to determine if a source is reliable.
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 healthcare provider will want to change fluids and narcotics prescribed. The healthcare provider should be notified of significant condition changes. The client may require additional diagnostic testing and imaging.
The changes suggest that the client's intracranial pressure is increasing. Explanation: Cushing's triad (apnea, bradycardia, and widening pulse pressure) is a hallmark of increasing intracranial pressure, which indicates that the adolescent's condition is deteriorating. It is correct that the healthcare provider must be alerted to significant changes and may need to change orders. The client may need additional testing. However, the primary reason to notify the healthcare provider is so the obvious increase in intracranial pressure can be managed using a holistic and emergent approach.
A healthy adolescent is hospitalized for new-onset diabetic ketoacidosis and is receiving IV and oral fluids. The nurse monitors the adolescent's fluid intake because quick fluid replacement may result in which condition? heart failure cardiovascular shock metabolic alkalosis cerebral edema
cerebral edema Explanation: Quick fluid replacement or fluid overload would make the adolescent vulnerable to developing cerebral edema and increased intracranial pressure. It would be unusual for an adolescent to develop heart failure unless overhydration was extreme. Cardiovascular shock most often occurs after heart damage secondary to a myocardial infarction. A client with ketoacidosis will not experience metabolic alkalosis from fluid replacement.
The nurse provides care to a client with anogenital warts. The nurse teaches that anogenital warts increase an adolescent female's risk of which condition? urinary tract infections dysmenorrhea infertility cervical cancer
cervical cancer Explanation: Anogenital warts are associated with human papillomavirus (HPV) and increase an adolescent female's risk of cervical cancer. This risk mandates treatment of all external lesions. HPV doesn't increase the risk of infertility, infections, or painful menstrual cycles.
Acetaminophen was given to an adolescent for headache. Which of the following parameters would indicate the effectiveness of the medication? change in behavior intermittent sleeping no change in vital signs no change in behavior
change in behavior Explanation: Positive changes in behavior and vital signs are indicators of an effective response to pain medication. Sleeping isn't a reliable indicator of pain relief because the teen may use sleep as a coping mechanism. Vital signs may or may not change.
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: clean the wound with povidone-iodine and apply a gauze dressing. cover the opening with petroleum gauze. call a physician and obtain a chest tray. reintroduce the tube and attach it to water seal drainage.
cover the opening with petroleum gauze. Explanation: If a chest tube is accidentally removed, the nurse should cover the insertion site with sterile petroleum gauze. The nurse should then observe the client for respiratory distress because tension pneumothorax may develop. If tension pneumothorax does develop, the nurse should remove the gauze to allow air to escape. The nurse shouldn't reintroduce the tube. Rather, the nurse should have another staff member call a physician so another tube can be introduced by the physician under sterile conditions.
According to Erikson, the psychosocial task of adolescence is the development of a sense of identity. A nurse can best promote the development of a hospitalized adolescent by: allowing parents and siblings to visit frequently. encouraging peer visitation. emphasizing the need to follow the facility regimen. arranging for tutoring in school work.
encouraging peer visitation. Explanation: Peer visitation gives the adolescent an opportunity to continue along the path toward independence and identity. Knowledge of the facility regimen prepares the adolescent for upcoming procedures but doesn't affect development. To achieve a sense of identity, the adolescent must gain independence from family. Tutoring may help maintain a positive self-image relative to schoolwork but doesn't affect development.
The nurse evaluates the care of an adolescent with a recent spinal cord injury. Which finding should lead the nurse to determine that spinal shock was resolving? hyperactive reflexes atonic urinary bladder flaccid paralysis widened pulse pressure
hyperactive reflexes Explanation: Spinal shock causes a loss of reflex activity below the level of the injury, resulting in bladder atony and flaccid paralysis. When the reflex arc returns, it tends to be overactive, resulting in spasticity. The reflexes and bladder become hypertonic during this phase of spinal shock resolution; sensation does not return. A widened pulse pressure is not associated with the resolution of spinal shock.
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? initiative industry identity autonomy
identity Explanation: According to Erikson's theory of personal development, the adolescent is in the stage of identity versus role confusion. During this stage, the body is changing as secondary sex characteristics emerge. The adolescent is trying to develop a sense of identity, and peer groups take on more importance. The hospitalized adolescent is separated from the peer group and the adolescent's body image may be altered. This alteration in body image may interfere with the ongoing development of the adolescent's identity. Toddlers are in the developmental stage of autonomy versus shame and doubt. Preschool children are in the stage of initiative versus guilt. School-age children are in the stage of industry versus inferiority.
Which interview strategy contributes to a poor nurse-adolescent relationship? asking open-ended questions and moving to more directive questions when possible maintaining objectivity by avoiding assumptions, judgments, and lectures interviewing adolescents with their parents present beginning with less-sensitive issues and proceeding to more-sensitive ones
interviewing adolescents with their parents present Explanation: When possible, adolescents should be interviewed without their parents present to ensure confidentiality and privacy. Interviewing adolescents with their parents present hinders the formation of the nurse-adolescent relationship. Avoiding assumptions, judgments, and lectures will increase the adolescents' comfort in disclosing sensitive information. Begin with less-sensitive questions so the adolescents won't feel threatened and uncomfortable and become uncooperative during the interview. Ask open-ended questions to give adolescents opportunities to share their psychosocial context.
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 threatening to discontinue care if the client doesn't comply emphasizing the long-term consequences of noncompliance reprimanding the adolescent for failing to comply with treatment
monitor intracranial pressure Explanation: Increased intracranial pressure (ICP) contributes to increasingly severe pathology, including potential for brain stem herniation, so monitoring and maintaining stable intracranial pressure is the priority. Systemic parameters and intracranial parameters are both essential though. The nurse takes actions to keep the intracranial pressure low by controlling factors that can cause elevated ICP; these action include monitoring for changes in oxygenation, temperature, glucose, blood pressure, and heart rhythm and rate. Maintaining the head in a neutral position is essential to keeping ICP within the desired limits.
When developing the care plan, the nurse anticipates including interventions that address which metabolic disorder? hypoglycemia metabolic alkalosis metabolic acidosis hyperkalemia
monospot test streptococcal antigen test throat culture Explanation: The common presenting symptoms of infectious mononucleosis vary greatly but commonly include fever, malaise, sore throat, and lymphadenopathy. Other conditions to exclude include strep and viruses. If these tests are negative, depending on other symptoms and severity, additional testing may be ordered, such as those to rule out conditions like leukemia.
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? support and guidance from parents a strict no-drug policy at their high school peer recognition that does not involve substance use the threat of legal charges if caught drinking or smoking marijuana
peer recognition that does not involve substance use Explanation: Peer acceptance and recognition is a very powerful force in the lives of adolescents, leading to positive or negative behavior depending on the child's peers. Although the influence of parents remains strong, peer acceptance combined with the adolescent's desire for independence can lead to disobeying the parents. The sanctions provided at school and in the community by law enforcement will support those teens that have other support in their lives, but are generally not sufficient to prevent substance use in adolescents lacking support at home and with peers.
A female adolescent client refuses to allow male nurses to care for her while she's hospitalized. Which of these health care rights is this adolescent exerting? right to competent care right to confidentiality of her medical record right to have an advance directive on file right to privacy
right to privacy Explanation: This adolescent is exhibiting her right to privacy when she requests that she doesn't want a male nurse to care for her. She also has a right to competent care, the right to have an advance directive on file, and a right to confidentiality. However, she isn't exercising these rights in this scenario.
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? supine lithotomy semi-Fowler prone
semi-Fowler Explanation: After an appendectomy for a ruptured appendix, assuming semi-Fowler or a right side-lying position helps localize the infection. These positions promote drainage from the peritoneal cavity and decrease the incidence of subdiaphragmatic abscesses.
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? the adolescent's future plans technique for monthly testicular self-examinations the adolescent's sterility need for a lot of psychological support
technique for monthly testicular self-examinations Explanation: Because the incidence of testicular cancer is increased in adulthood among children who have had undescended testes, it is extremely important to teach the adolescent how to perform the testicular self-examination monthly. The undescended testicle is removed to reduce the risk for cancer in that testicle. Removal of a testis would not necessarily make the adolescent sterile because the other testicle remains. Although discussing the adolescent's future plans is important, it is not the priority at this time. Because the adolescent has been dealing with the situation for a long time, the need for a sports physical at this time should not be a cause of emotional distress requiring a lot of psychological support.
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? "Gently press on the lower left quadrant of your child's abdomen to test for rebound tenderness." "Bring your child into the emergency department immediately before the appendix has a chance to rupture." "Give your child a laxative to rule out the possibility that constipation is causing the pain." "It's most likely the flu because your child is too young to have appendicitis."
"Bring your child into the emergency department immediately before the appendix has a chance to rupture." Explanation: Abdominal pain, low-grade fever, and vomiting are cardinal signs of appendicitis. The nurse should instruct the parent to take the child to the emergency department. Telling the parent to give the child a laxative is inappropriate because if appendicitis is the cause of the pain the appendix may rupture as a result of the drug. Appendicitis can occur at any age. Rebound tenderness is a symptom of appendicitis, but this finding would be found in the right lower quadrant, not the left.
An adolescent girl with a seizure disorder controlled with phenytoin and carbamazepine asks the nurse about getting married and having children. Which response by the nurse would be most appropriate? "You probably should not consider having children until your seizures are cured." "Your children will not necessarily have an increased risk for a seizure disorder." "Women who have seizure disorders commonly have a difficult time conceiving." "When you decide to have children, talk to the health care provider (HCP) about changing your medication."
"When you decide to have children, talk to the health care provider (HCP) about changing your medication." Explanation: Phenytoin sodium is a known teratogenic agent, causing numerous fetal problems. Therefore, the adolescent should be advised to talk to the HCP to see if changing the medication is possible. Additionally, anticonvulsant requirements usually increase during pregnancy. Seizures can be controlled but cannot be cured. There is a familial tendency for seizure disorders. Seizure disorders and infertility are not related.
A nurse is reviewing discharge instructions with the parents of an adolescent who sustained a head injury to the frontal lobe of the brain. When discussing possible consequences of the injury, which of the following is the most important information to give the parents? "Your child may develop sudden problems with vision." "Your child may exhibit drastic personality changes." "Your child will gradually lose the ability to hear." "Your child may mention unusual numbness and tingling."
"Your child may exhibit drastic personality changes." Explanation: The frontal lobe regulates personality and judgment. The occipital lobe regulates vision, the temporal lobe regulates hearing, and the parietal lobe regulates sensation.
An adolescent client is seeking services at a local clinic without their parents. The client states that they have been having consensual sex with a classmate and asks for a sexually transmitted infection (STI) screening. What should the nurse do? Call the client's parents, and seek permission for the STI screen. Submit a report to the local child welfare agency. Provide a pregnancy test only. Inform the client what will be involved with STI screening.
Inform the client what will be involved with STI screening. Explanation: Minors are allowed to provide consent for their own STI services in many areas. The nurse should tell the minor what is involved in STI screening before proceeding. It is not appropriate to contact a child welfare agency or the minor's parents if they are seeking these services. A pregnancy test may be indicated, but it should not exclude the STI screening.
An adolescent is on the football team and practices in the morning and afternoon before school starts for the year. The temperature on the field has been high. The school nurse has been called to the practice field because the adolescent is now reporting that they have muscle cramps, nausea, and dizziness. Which action should the school nurse do first? Elevate the child's legs. Administer cold water with ice cubes. Move the adolescent to a cool environment. Take the adolescent's temperature.
Move the adolescent to a cool environment. Explanation: The adolescent is most likely experiencing heat exhaustion or heat collapse, which are common after vigorous exercise in a hot environment. Symptoms result from loss of fluids and include nausea, vomiting, dizziness, headache, and thirst. Treatment consists of moving the adolescent to a cool environment and giving cool liquids. Cool liquids are easier to drink than cold liquids. Taking the adolescent's temperature would be appropriate once these actions have been completed. However, the adolescent's temperature is likely to be normal or only mildly elevated. Elevating the child's legs is a measure that is used to treat dizziness, but it should only be implemented after the child has been moved to a cooler environment.
Click to highlight the findings that may indicate concerns that will require follow up. 0800: Client is a 14-year-old who was diagnosed at birth with pulmonary stenosis. Guardian reports that client had a dental procedure three days prior which the client tolerated well. Client reports feeling lethargic and weak. Skin warm and pink. Capillary Refill 2 seconds. Vital Signs: Temperature: 103°F (39.4°C). Blood Pressure: 112/72 mm Hg. Pulse Rate: 100 beats/minute; Respiratory Rate: 18 breaths/minute. SPO2: 96% on room air.
client had a dental procedure three days prior Client reports feeling lethargic and weak Temperature: 103°F (39.4°C) Due to the history of pulmonary stenosis and recent dental procedure, the client is at risk for endocarditis. The nurse should be aware of findings that require follow-up. Client had a recent dental procedure which places clients with valvular stenosis at risk for endocarditis. Additionally, the client is experiencing an elevated temperature which is a manifestation of acute endocarditis. The client reports feeling lethargic and weak which is a manifestation of endocarditis. The client's blood pressure, pulse rate, respiratory rate, and SPO2 are currently within normal limits. Skin that is warm and pink is a normal finding. The skin will need to be monitored for decline which may be indicated by coolness, clamminess, and cyanosis.
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? reviewing data about common teenage lifestyle choices creating a safe environment for sharing information disclosing and explaining personal lifestyle choices validating the current lifestyle choices of the teenagers
creating a safe environment for sharing information Explanation: Creating an environment where the teenagers feel safe to share their information leads to therapeutic communication that is client focused. This helps to establish trust, which facilitates a more successful program. The other options block the ability of the teenagers to share their thoughts and feelings openly. Add a Note
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 threatening to discontinue care if the client doesn't comply emphasizing the long-term consequences of noncompliance reprimanding the adolescent for failing to comply with treatment
letting the adolescent participate in planning and scheduling of treatments Explanation: Because the adolescent is striving for independence, healthcare providers should promote self-reliance whenever possible, such as by letting the client participate in planning and scheduling treatments. The client can help establish realistic goals and evaluation outcomes as well as help schedule procedures and chemotherapy doses to minimize lifestyle disruptions. Adolescents are oriented in the present and have relatively little concern for the long-term consequences of their behavior. Reprimanding the client or threatening to discontinue care isn't likely to improve compliance and isn't in the client's best interest.
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? costovertebral angle tenderness widening pulse pressure low-grade fever gross hematuria
low-grade fever Explanation: The most common manifestations of appendicitis include right lower quadrant pain, localized tenderness, and a low-grade fever. Other signs of inflammation, including increased pulse and respiratory rates, may be present. Costovertebral angle tenderness and gross hematuria are associated with urologic problems. Widening pulse pressure is seen in increased intracranial pressure.
An adolescent with type 1 diabetes is monitoring her blood glucose level at home. Which action indicates that the client understands appropriate care management strategies for a blood glucose level of 250 mg/dL (13.9 mmol/L)? skipping the next dose of insulin taking insulin eating a high-carbohydrate meal injecting glucagon
taking insulin Explanation: A blood glucose level of 250 mg/dL (13.9 mmol/L) is indicative of hyperglycemia. The adolescent should take insulin to lower glucose levels, drink water to prevent dehydration, and contact the health care provider.Skipping a dose of insulin is inappropriate without first contacting the primary care provider. In this case, skipping a dose would worsen the adolescent's hyperglycemia.Hypoglycemic episodes are managed by ingesting foods or beverages with high-carbohydrate content.Glucagon is used if the adolescent has hypoglycemia and is unconscious.
An adolescent is receiving chemotherapy for lymphoma. Which statement by the adolescent supports a nursing diagnosis of Deficient knowledge related to mouth care? "I use a soft toothbrush to clean my teeth." "I remove white patches from my tongue and cheeks with my toothbrush." "I rinse my mouth every 2 to 4 hours with a solution of baking soda and water." "I don't use commercial mouthwashes."
"I remove white patches from my tongue and cheeks with my toothbrush." Explanation: White patches on the tongue and oral mucosa indicate infection; the adolescent should report the patches, not remove them. Using a soft toothbrush is appropriate because it prevents injury to the fragile oral mucosa. Rinsing the mouth every 2 to 4 hours with a nonirritating solution, such as baking soda and water or normal saline solution helps prevent stomatitis. Avoiding commercial mouthwashes is appropriate because they may contain alcohol, which may dry the oral mucosa.
A hospitalized adolescent diagnosed with anorexia nervosa refuses to comply with their daily before-breakfast weigh-in. The client states that they just drank a glass of water, which they feel will unfairly increase their weight. What is the nurse's best response to the client? "You must weigh in every day at this time. Please step on the scale." "Don't drink or eat for 2 hours, and then I'll weigh you." "You're here to gain weight, so that will work in your favor." "If you don't get on the scale, I'll be forced to call your health care provider."
"You must weigh in every day at this time. Please step on the scale." Explanation: In responding to the client, the nurse must be nonjudgmental and matter-of-fact. Telling them that weight gain is in their favor ignores the client's extreme fear of gaining weight. Putting off the weigh-in for 2 hours allows the client to manipulate the nurse and interferes with the need to weigh the client at the same time each day. Threatening to call the health care provider is not likely to build rapport or a working relationship with the client.
An adolescent is admitted for treatment of bulimia nervosa. When developing the care plan, the nurse anticipates including interventions that address which metabolic disorder? hypoglycemia metabolic alkalosis hyperkalemia metabolic acidosis
"Your child may exhibit drastic personality changes." Explanation: The frontal lobe regulates personality and judgment. The occipital lobe regulates vision, the temporal lobe regulates hearing, and the parietal lobe regulates sensation.
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's mood is related to a lack of sun exposure. Determine whether the adolescent has had intermittent episodes of euphoria. Determine whether the adolescent has developed a plan for committing suicide. Determine whether the adolescent has had trouble adjusting to a stressful event.
Determine whether the adolescent has developed a plan for committing suicide. Explanation: The adolescent is experiencing a major depression, which is a type of mood disturbance that lasts over 2 weeks. Symptoms may include overwhelming feelings of sadness and grief, loss of interest or pleasure in activities that are usually enjoyed, and feelings of worthlessness or guilt. It may result in poor sleep, a change in appetite, severe fatigue, and difficulty concentrating. It increases the risk of suicide. The nurse needs to determine whether the adolescent has a plan for suicide, which would increase the likelihood that a suicide would occur.
A 16-year-old client requires chemotherapy for leukemia. The client's parents support the health care provider's recommendation, but the client is refusing treatment. What is the nurse's best initial action? Give advice to the client's parents on the best method of convincing the client to take the treatment. Inform the client that if the parents agree with the treatment plan, their consent will be honored. Advise the client to take the treatment because the health care provider knows best. Request that the health care provider thoroughly explain the benefits and consequences of treatment to the client.
Request that the health care provider thoroughly explain the benefits and consequences of treatment to the client. Explanation: The nurse has a responsibility to the client and should act as an advocate. In this situation, it is best, and most appropriate, for a 16-year-old client to understand the treatment being discussed. After a discussion and understanding, if the client refuses, then the client can be instructed that the decision of the parents will be honored. The other options do not demonstrate the nurse's understanding of client advocacy and the client's right to choice.
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? coping with a chronic disease management of the therapeutic regimen relocating closer to the hospital risk for injury and readmission
management of the therapeutic regimen Explanation: The priority immediately after recovery is therapy management, including reviewing that the interruption of insulin administration may result in diabetic ketoacidosis. The multiple admissions suggest that the adolescent either does not understand the consequences of the disease or is making choices that are not consistent with the health teaching. This is an opportunity to review those choices.
Which substance should the nurse include in the teaching plan for a teenager with acne who has requested information about cleansing the affected skin? antibacterial soap hydrogen peroxide witch hazel mild soap and water
mild soap and water Explanation: Acne is a disorder of the pilosebaceous follicles (hair follicles and sebaceous gland complex). During adolescence, the secretions of the sebaceous glands increase, altering the follicular lining and causing occlusion of the ducts with accumulated sebum. Bacteria in the follicle then cause an infection. Frequent washing of affected areas with soap and water is recommended to act as a mild peeling agent and reduce secondary infection. Witch hazel is an astringent that can be used after thoroughly cleansing the skin. Hydrogen peroxide is a poor cleansing agent for skin with acne. Using antibacterial soap on the face can easily over-dry and irritate the skin.
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. A condom only needs to be placed on the penis immediately before ejaculation. Never reuse a condom. Leave a 1/2-inch space at the tip of the condom. The condom should be applied on an erect penis. Condoms should be stored in a cool, dry place to prevent damage.
Never reuse a condom. Leave a 1/2-inch space at the tip of the condom. The condom should be applied on an erect penis. Condoms should be stored in a cool, dry place to prevent damage. With proper instruction and use, condoms can be a reliable method of birth control and STI prevention. Condoms should be stored in a cool, dry place to prevent heat damage. A 1/2-inch space should be left at the tip of the condom to allow for collection of the ejaculate and to prevent tearing of the condom. A condom is applied after the penis is erect but before insertion into the partner. A condom should not be reused.
An adolescent tells the nurse that they would like to use tampons during their period. What should the nurse do first? Determine whether the client is sexually active. Refer the client to a specialist in adolescent gynecology. Assess the client's usual menstrual flow pattern. Provide information about preventing toxic shock syndrome.
Provide information about preventing toxic shock syndrome. Explanation: The nurse should provide the adolescent with information about toxic shock syndrome because of the identified relationship between tampon use and the syndrome's development. Additionally, about 95% of cases of toxic shock syndrome occur during menses. Most adolescent females can use tampons safely if they change them frequently. Using tampons is not related to menstrual flow or sexual activity. There is no need to refer the girl to a gynecologist; a nurse can provide health teaching about tampon use.
An adolescent reports sore throat and fatigue. The nurse observes a fever and swollen tonsils. Which diagnostic test(s) does the nurse prepare to collect during this initial encounter? Select all that apply. chest X-ray streptococcal antigen test throat culture monospot test allergy scratch test
metabolic alkalosis Explanation: In a client with bulimia nervosa, metabolic alkalosis may occur secondary to hydrogen loss caused by frequent, self-induced vomiting. Typically, the blood glucose level is within normal limits, making hypoglycemia unlikely. In bulimia nervosa, hypokalemia is more common than hyperkalemia and typically results from potassium loss related to frequent vomiting.
An overweight adolescent client has lost 12 lb (5.4 kg) in 8 weeks using diet strategies. The client reaches a weight loss plateau and is discouraged. The nurse instructs the client to keep a food diary for what purpose? to provide a written record of caloric intake for the nurse to help the client stay busy and more focused on losing weight to help the client analyze how much food is consumed and when to help the nurse determine whether the diet is being followed
to help the client analyze how much food is consumed and when Explanation: Keeping a food diary allows the adolescent client to use the cognitive level of formal operations to help identify and evaluate eating behaviors of which he may not be aware. It is primarily a tool to assist in self-correction and behavior modification. The client does not need to be preoccupied with weight loss. The nurse can provide insights based on the diary entries, but this device is not for the nurse.
A nurse is providing health teaching to a group of adolescent girls. The focus is on urinary tract infections. One of the girls tells the nurse that she wants to know more about cystitis. Which statement by the nurse is the most appropriate response? "This is a minor bacterial infection of the bladder that can occur at anytime." "This is a serious condition that occurs after intercourse or vaginal cleanses." "This condition can result from irritation and inflammation from sexual activity." "This condition happens frequently in young women and is not harmful."
"This condition can result from irritation and inflammation from sexual activity." Explanation: Cystitis is a lower urinary tract infection. One cause seen in young adolescent women is after their first sexual intercourse. The urinary tract infections occur because of inflammation and local irritation caused by sexual activity. Bladder infections can lead to complications, and therefore are not minor or harmless. A bladder or urethral infection is not the result of vaginal cleanses such as douches.
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. The client will need supervision for the first self-administrations. Adolescents tend to be uncooperative with instructions from adults. The client will learn better using a recorded video tutorial.
Adolescents are worried about appearing different from their peers. Explanation: Adolescents have a strong need to belong, and they seek social approval from their peers. Knowing this information will help the nurse construct an effective teaching plan. According to Piaget, adolescents are at the formal operations stage and are capable of deductive, reflective, and hypothetical reasoning. According to Erikson's stages of psychosocial development, adolescence is the stage of identity versus role confusion. During this stage, the adolescent strives to establish a sense of identity. There is no reason to think the adolescent will be uncooperative. Many people find video tutorials useful, but a return demonstration is the best way to ensure the client understands and is able to follow the instructions. The nurse can assess the client's abilities without the client requiring supervision at home.
