PrepU - Adult Nursing III - Adolescent - Chapter 29

A 16-year-old girl has arrived for her sports physical with a new piercing in her navel. Which response by the nurse is best? a. "Be sure to clean the navel several times a day." b. "This is a risk for hepatitis, tetanus, and AIDS." c. "This is a wound and can become infected." d. "I hope for your sake the needle was clean."

a. "Be sure to clean the navel several times a day." Explanation: The best response is to describe the proper care using frequent cleansing with antibacterial soap. It is too late for warnings about the dangers of piercing such as skin- or blood-borne infections, or disease from unclean needles

The nurse is collecting data from a 15-year-old boy who is being seen at the ambulatory care clinic for immunizations. During the initial assessment, he voices concerns about being shorter than his peers. What response by the nurse is indicated? a. "Boys your age will often continue growing for a few more years." b. "Being short is nothing to be ashamed of." c. "I am sure you are not the shortest guy in your class." d. "Are the other men in your family short?"

a. "Boys your age will often continue growing for a few more years." Explanation: Teenage boys can experience growth in height until age 17.5. The nurse should reassure the teen that this may happen for him. Telling the client not to be ashamed, or assuring him it is not as short as his peers fails to provide information or support. Determining the height of the other men in the family may be indicated at a later time but is not the most appropriate initial comment.

The nurse is working with a 12-year-old who has recently experienced family instability and abuse. 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? a. Development of an antisocial identity b. Confusion about role in the world c. Physical and emotional aggression in relationships d. Dissociative identity disorder

b. Confusion about role in the world Explanation: Erikson identifies the primary developmental task of early adolescence as identity versus role confusion. That is, unsuccessful development results in confusion about role and identity. This does not necessarily result in aggression or antisocial behavior. Dissociative identity disorder is a specific psychiatric disorder.

According to Erikson, the adolescent develops his or her own sense of being an independent person with individual thoughts and goals. This stage is referred to as: a. identity vs. role confusion. b. industry vs. inferiority. c. intimacy vs. isolation. d. autonomy vs. doubt and shame.

a. identity vs. role confusion. Explanation: Adolescents must develop their own personal identity—a sense of being independent people with unique ideals and goals.

Which intervention would probably be most effective in preventing an adolescent from attempting suicide with an overdose again? a. Helping him locate a close friend at school b. Helping him learn better problem solving c. Teaching his parents to keep medicine in a locked cabinet d. Assessing his financial level

b. Helping him learn better problem solving Explanation: Suicide is a solution when there does not appear to be any other solution. Helping an adolescent learn better problem solving can help prevent a second attempt

The activity that would best foster the developmental task of an adolescent who is physically challenged would be: a. having a teacher bring her school homework in for her. b. deciding whether she wants her bath before or after lunch. c. watching television on the set in her room. d. talking to another adolescent who has a similar disorder.

d. talking to another adolescent who has a similar disorder. Explanation: A sense of identity is developed by "trying on" roles and discussing values and goals with others.

A high-school athlete comes to the emergency department with hypertension, aggressiveness, and psychosis. What question would be important for the nurse to ask the client? a. "Do you take anabolic steroids?" b. "Do you take human growth hormone?" c. "Do you take cocaine?" d. "Do you take amphetamines?"

a. "Do you take anabolic steroids?" Explanation: Anabolic steroids are used by adolescents who play sports. They are used to enhance the adolescent's athletic ability. They produce euphoria and lessened fatigue. Unfortunately, steroid use can also lead to early closure of the epiphyseal plate, acne, elevated triglyceride levels, hypertension, aggressiveness, and possibly psychosis. Human growth hormone is also used to enhance athletic performance. The side effects of it are joint pain and swelling and the development of diabetes. Amphetamines provide a sense of well-being, alertness, and self-esteem. They can produce paranoia and extreme restlessness. Cocaine produces increased pulse and respirations, increased temperature, and blood pressure and decreased appetite.

A 13-year-old girl has grown rapidly in height over the past 2 years and is taller than most of the boys in her class. She wonders when she will stop growing. What should the nurse tell her as a general guideline for the ages at which most girls stop growing? a. 20 to 21 years old b. 16 to 17 years old c. 18 to 19 years old d. 14 to 15 years old

b. 16 to 17 years old Explanation: Growth stops with closure of the epiphyseal lines of long bones which occurs at about 16 or 17 years of age in females and about 18 to 20 years of age in males.

Based on the most frequent cause of death in adolescents, what preventive measure would the nurse most want to teach an adolescent? a. Firearm safety b. Home safety c. Motor vehicle safety d. Water safety

c. Motor vehicle safety Explanation: Motor vehicle accidents are the number one cause of death in adolescents.

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. A sense of trust and identity b. An understanding of socialization and of isolation c. An ability to be autonomous d. A willingness to take initiative

a. A sense of trust and identity Explanation: In order to be intimate or to share one's deepest feelings with another person, it is impossible unless both persons have established a sense of trust and a sense of identity. Being autonomous or taking initiative are not aspects that lead toward intimate relationships. Socialization and isolation are not relevant to the establishment of intimate relationships.

The school nurse is preparing health promotion presentations regarding unintentional injuries for a high school health fair. On which topic should the nurse place as the priority when preparing the presentation? a. Poison prevention b. Water sports injuries c. Motor vehicle safety d. Drug and alcohol use prevention

c. Motor vehicle safety Explanation: All options should be included in the presentation, but motor vehicle safety has the highest priority because motor vehicle accidents are the leading cause of injury and death followed by poisoning, which includes prescription drug overdose.

True adolescence is said to begin when what occurs? a. The areola separate from the contour of the breasts in the female. b. The growth spurt in the female ends. c. Sperm is produced in the male. d. The voice deepens in the male.

c. Sperm is produced in the male. Explanation: True adolescence begins with the onset of menstruation in the female and the production of sperm in the male

Nurses should provide anticipatory guidance to males to prepare them for what particular pubertal change in late adolescence? a. Breast enlargement b. Nocturnal emissions c. Reddening of the scrotum d. Lengthening of the penis

b. Nocturnal emissions Explanation: This involuntary ejaculation during the night can be disturbing to the adolescent male who has little or no understanding of what is happening in his body. Lengthening of the penis begins to occur in early adolescence as does reddening of the scrotum. Breast enlargement occurs in some males in middle adolescence and resolves in late adolescence.

The school nurse is assessing a 16-year-old girl who was removed from class because of disruptive behavior. She arrives in the nurse's office with dilated pupils and is talking rapidly. Which drug might she be using? a. Opiates b. Marijuana c. Barbiturates d. Amphetamines

d. Amphetamines Explanation: Amphetamine use manifests as euphoria with rapid talking and dilated pupils. Signs of opiate use are drowsiness and constricted pupils. Barbiturates typically cause a sense of euphoria followed by depression. Marijuana users are typically relaxed and uninhibited.

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? a. Children from ages 2 to 7 years investigate and explore the environment and look at things from their own point of view. b. After age 12 children can think in the abstract, including complex problem solving. c. From ages 7 to 11 years, children internalize actions and can perform them in the mind. d. Up to age 2, children learn by touching, tasting, and feeling. They learn to control body movement.

b. After age 12 children can think in the abstract, including complex problem solving. Explanation: The nurse should explain that there are four levels of cognitive development in Piaget's theory. The sensorimotor level is up to age 2 where children learn by touching, tasting, and feeling. They learn to control body movement. Preoperational level is children from ages 2 to 7 years who investigate and explore the environment and look at things from their own point of view. At the concrete operations level from ages 7 to 11 years, children internalize actions and can perform them in the mind. At the formal operations after the age 12 children can think in the abstract. Complex problem solving is included in this category

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? a. "When you are thinking about girls or having girlfriends you might have a wet dream." b. "It will be several years before you will start having wet dreams." c. "Having wet dreams indicates that your body is going through a process of maturing." d. "It is not common to wet the bed or urinate when you have a wet dream."

c. "Having wet dreams indicates that your body is going through a process of maturing." Explanation: In boys, the appearance of nocturnal emissions ("wet dreams") is often used as the indication that the preadolescent period has ended and that the adolescent is maturing into an adult. Nocturnal emissions usually occur at about the age of 11 in boys. Wet dreams are not associated with urination. Boys at this age start thinking of relationships with girls, but this is not the best response.

With summer approaching, the nurse discusses sun safety with a group of teen girls. Which suggestion is most likely to be followed? a. Do not attempt to get a tan. b. Wear a hat when in the sun. c. Limit sun exposure between 10:00 AM and 2:00 PM. d. Wear sunglasses.

d. Wear sunglasses. Explanation: Sunglasses can be a fashion statement and are likely to be accepted. The other pieces of advice are less appealing to adolescents who link a tan body to beauty. Unfortunately, sun exposure is cumulative over a lifetime, and much of it occurs in youth, making protecting young skin important.

The parents are concerned their 14-year-old child is always eating. The child weighs 54 kg and is 65 inches (165 cm) tall. What is the best explanation the nurse can give the parents? a. "He is substituting food for unfilled needs." b. "The calories help his body increase muscle mass." c. "His calorie intake predisposes him to future obesity." d. "He needs the calories because he participates in sports."

b. "The calories help his body increase muscle mass." Explanation: Adolescents grow rapidly and mature dramatically during the period from ages 13 to 20 years. An adolescent needs an increased number of calories to support the rapid body growth that occurs. Foods must come from a variety of sources to supply the necessary amounts of carbohydrates, vitamins, protein, and minerals. Boys typically gain about 15 to 55 pounds (7 to 25 kg) during their teenage years. The calorie intake will not predispose him to future obesity unless it is continuously excessive. The majority of adolescents eat as part of their development, not as an emotional need.

A 15-year-old is seen at a health care facility for facial acne. When counseling him, the nurse would teach him that the basic cause of his acne is: a. vitamin deficiency from an inadequate diet. b. thyroid-gland secretions increasing with adolescence. c. activation of androgen hormones. d. lack of showering adequately after gym class.

c. activation of androgen hormones. Explanation: As androgen rises with puberty, sebaceous glands are activated to increase production of sebum, which leads to plugging of ducts (comedones).

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? a. "Are the guns in your home locked in a safe?" b. "Have you been taught how to use a gun?" c. "Do you understand that it is important for you not to handle a gun?" d. "Do you and your dad hunt?"

a. "Are the guns in your home locked in a safe?" Explanation: Common causes of death in adolescents are homicide and self-harm. These are related to the easy accessibility of guns, especially when added to depression, binge drinking, and impulsivity. Gang violence and the desire to protect themselves are additional factors. Having the gun locked in a safe provides a way for limited access. Knowing how to use a gun and going hunting demonstrate expertise, but the safest way to prevent harm is to have the gun locked when not in use for these purposes. Telling the adolescent it is important not to use a gun provides no explanation why and comes across as a rule to be broken.

The nurse is admitting a 15-year-old to the hospital pediatric unit. What does the nurse recognize as a priority for this adolescent? a. The adolescent's need for privacy should be respected. b. The adolescent's need for parental support should be discussed. c. The adolescent should be given freedom to participate in unit activities as desired. d. The adolescent should be encouraged to call friends often.

a. The adolescent's need for privacy should be respected. Explanation: Adolescents must be given privacy, individualized attention, confidentiality, and the right to participate in decisions about their health care.

What anticipatory guidance can the nurse provide the girl who has noted the development of breast buds? a. The growth spurt will begin immediately with menarche. b. Menarche should follow in about 2 years. c. Adult height will be reached at the time of menarche. d. Breast development will be complete with 12 months.

b. Menarche should follow in about 2 years. Explanation: Menarche usually follows within 2 years of the first signs of breast development. Peak height velocity (PVH) in girls occurs 6 to 12 months following menarche. It does not follow immediately. Breast development progresses through several stages and will not be complete until late puberty. Adult height is not reached at the time of menarche but about 6 to 12 months following menarche.

The nursing instructor is leading a class discussion on the various aspects of adolescents. The instructors determines the class is successful after the students correctly choose which milestone as the beginning of adolescence? a. The child becoming self-supported b. The fine motor skills fully developed c. The beginning of puberty d. The deciduous teeth falling out

c. The beginning of puberty Explanation: Early adolescence (preadolescence, pubescence) begins with a dramatic growth spurt that signals the advent of puberty or reproductive maturity. The deciduous teeth are all out around the age of 10 or 11. Children usually are not self-supported. Fine motor skills continue to develop through adolescence.

The physician has made a notation in the medical record of a 17-year-old that the teen is not demonstrating successful completion of Erikson's stages of development. What behavior would be consistent with this assessment? a. The teen is anxious to move away from his parent's home. b. The teen is sexually promiscuous. c. The teen is distrustful of others. d. The teen is uncertain and frequently unable to make decisions.

d. The teen is uncertain and frequently unable to make decisions. Explanation: According to Erikson's stages of development, the teen develops a sense of identity. Failure to successfully complete this stage will result in a lack of self confidence and an inability to see one's self as in independent being. The establishment of the ability to trust is completed in an earlier stage of psychosocial development. A desire to move away from the parental home is not uncommon and is not a sign of impaired navigation of this level of psychosocial development.

The nurse is instructing a 12½-year-old boy who says, "I am too short! Girls are taller than I am. Guess I won't be playing basketball." What instruction is best included in the plan of care? Select all that apply. a. "Girls begin to grow rapidly at a younger age than boys do. Boys start later and grow longer." b. "You are at the age now when most boys begin their growth spurt and grow very rapidly." c. "If you know how tall you were at age 3, you can double that and predict fairly well how tall you will get." d. "You can't control when and how much you will grow. Basketball can use some really fast guards." e. "There are a lot of size differences in your age group now because everyone enters puberty and grows at slightly different times than others." f. "You could add as much as 12 inches to your height before you stop growing."

a. "Girls begin to grow rapidly at a younger age than boys do. Boys start later and grow longer." e. "There are a lot of size differences in your age group now because everyone enters puberty and grows at slightly different times than others." f. "You could add as much as 12 inches to your height before you stop growing." Explanation: The information about girls growing faster than boys, about differences in size within his age group, and about his growth potential is accurate and addresses concerns implied in his comments to the nurse. Most boys' growth spurts begin near 14 years, not 12½. Height should be doubled at 2 years to predict adult size. The growth control and basketball remarks minimize his concerns and provide no information.

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? a. Ask her caregivers to bring her siblings and friends to visit. b. Call the hospital's mental health unit to see if she can get some counseling. c. Suggest that she read books and magazines from the hospital bookmobile. d. Take her to the teen lounge so she can meet other teens, use a phone, and check her e-mail.

d. Take her to the teen lounge so she can meet other teens, use a phone, and check her e-mail. Explanation: Adolescents need access to their peers so they can keep up social contacts. Access to a phone, computer, and e-mail will help the teen stay connected. Recreation areas are important. In settings specifically designed for adolescents, recreation rooms can provide an area where teens can gather to do schoolwork, play games and cards, and socialize. Because she is 100 miles from home, a visit from friends might be difficult.

The nurse is caring for a 13-year-old girl. The child has been identified as overweight with no underlying psychological or secondary causes. The nurse is reviewing the child's weight-loss progress and nutrition at a follow-up visit. What finding indicates a need for further discussion and teaching? a. "Her goal is to be a size smaller by our vacation in two weeks." b. "Our whole family has changed our eating habits." c. "My daughter is helping us plan our family's weekly menu." d. "We are using family outings and activities as a reward for weight loss."

a. "Her goal is to be a size smaller by our vacation in two weeks." Explanation: The mother must be reminded that a successful weight loss program emphasizes long-term permanent changes, not rapid weight loss or short-term diets to meet a short-term goal.

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? a. "I need to have 4 servings of fruit each day." b. "Because of my age, my dairy intake is unlimited." c. "I avoid all fat intake." d. "To lose weight my protein intake should be limited to 2 to 4 servings per day."

a. "I need to have 4 servings of fruit each day." Explanation: The sedentary teen needs to consume approximately 1,600 calories each day. The recommended number of daily servings of fruit is four. A balanced diet includes a small amount of fat. To avoid all fat could place the child's health at risk. Protein intake is important for the development of tissue. The teen will need about 5 ounces of protein daily.

During a visit to the school nurse, an adolescent confides in recently having homosexual feelings. How should the nurse best respond to the adolescent? a. "Would you like to talk about these feelings?" b. "Do these feelings make you feel bad about yourself?" c. "How long have you been having these feelings?" d. "These feelings are normal for your age."

a. "Would you like to talk about these feelings?" Explanation: The task of forming an identity is for adolescents to decide who they are and what kind of person they will be. One of the challenges of identity is to accept their changed body image. During adolescence, individuals begin to explore their sexual preferences and may question their gender identity. Encourage an open dialogue with adolescents to assist them to process their feelings and establish their own identity. The nurse should not be judgmental. Because the adolescent has had feelings does not mean the the adolescent is homosexual, nor does it imply there is something wrong that needs to be "fixed."

The school nurse is meeting with a group of 11-year-old girls to discuss expected puberty changes in their bodies. When one of the girls states, "I just feel like my whole body is changing and I don't know why" what should the nurse point out to this group? a. "You have lots of hormone changes going on right now." b. "Your other friends are feeling like this too." c. "You may feel like you are changing, but you still look the same." d. "You will feel better about yourself as you get older."

a. "You have lots of hormone changes going on right now." Explanation: Preadolescents need information about their changing bodies and feelings. Sex education that includes information about the hormonal changes that are occurring or will occur is necessary to help them through this developmental stage. Although adjustments will occur as the child gets older and friends are important, these responses are not the most direct and appropriate.

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? a. Allow the adolescent to choose the time for the dressing change. b. Have the school provide homework. c. Have the adolescent go to the teen room every day. d. Teach the parents to perform dressing changes at home.

a. Allow the adolescent to choose the time for the dressing change. Explanation: Achieving a sense of identity may be difficult for adolescents who have a chronic illness. Some of the nursing actions which encourage of identity in the chronically ill adolescent include: respecting food preferences; allowing the adolescent to choose the time for the dressing changes; teaching the name, actions and possible side effects of medication; and respecting modesty. The school can provide homework so the adolescent does not get further behind in school work, and the teen can go to the teen room each day. These provide a good emotional outlet, but they do not promote independence. Teaching the parents to do the dressing changes makes the adolescent dependent on the parents. If the dressings are at a location the adolescent can reach and dexterity is not limited, then the adolescent should be allowed self care.

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? a. Autonomy b. Generativity c. Initiative d. Industry

a. Autonomy Explanation: In revisiting the stage of autonomy, the adolescent is seeking out ways to express his or her individuality in an effective manner. The adolescent would avoid behaviors that would "shame" or ridicule him or her in front of his or her peers. The sense of industry is again encountered as the adolescent makes his or her choice to participate in different activities at school, in the community, at church, and in the workforce. Initiative is revisited as the adolescent develops his or her vision for what he or she might become. Generativity largely involves establishment of career and work.

The nurse is meeting with a group of caregivers of adolescents and discussing sex and sexuality, including how to discuss these issues with their children. Which comment should the nurse prioritize with this group of caregivers? a. Being honest and straightforward with teenagers will encourage them to ask about subjects like sexuality. b. Most schools have excellent programs to teach adolescents about sex and sexuality. c. Teenagers spend so much time with their peers, and that is usually how they find out about sex. d. Internet resources, movies, and television have the most accurate and current information for your adolescent to learn about sexuality issues.

a. Being honest and straightforward with teenagers will encourage them to ask about subjects like sexuality. Explanation: The most important aspect of discussions about sexuality with adolescents is giving honest, straightforward answers in an atmosphere of caring concern. Children whose need for information is not met through family, school, or community programs will get the information—often inaccurately—from peers, movies, television, or other media.

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? a. 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. b. He is not developmentally mature enough to make healthy choices about the ways in which he spends his time, so it would be helpful if they would make a schedule for him that includes about a half-hour per day to talk with his girlfriend. c. He has chosen a girl who is overly dependent on him. They should talk to him about making sure he meets his own needs, including doing the schoolwork he enjoys, in any relationship. d. He is not developmentally mature enough to have an intimate relationship with one girl; they should encourage him to spend time with groups of friends rather than time alone with his girlfriend.

a. 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. Explanation: When identity has been established, generally between the ages of 16 and 18 years, adolescents seek intimate relationships, usually with members of the opposite sex. Intimacy, which is mutual sharing of one's deepest feelings with another person, is impossible unless both persons have established a sense of trust and a sense of identity. Intimate relationships are a preparation for long-term relationships, and people who fail to achieve intimacy may develop feelings of isolation and experience chronic difficulty in communicating with others.

The nurse is meeting with a group of caregivers of adolescents. Which example should the nurse point out is most effective for the caregiver to support the adolescent? a. Let them choose their hairstyle, even though it may not look the best for them. b. Leave pamphlets about topics such as drugs and alcohol in their room so they can read them. c. Our house rules are stricter than their friends but everyone follows the same rules in our home. d. Discourage spending too much time with school friends since we know they can be a negative influence.

a. Let them choose their hairstyle, even though it may not look the best for them. Explanation: The adolescent whose family caregivers make it difficult to conform are adding another stress to an already emotion-laden period. By allowing the adolescent to follow trends and fads in clothing choices, hairstyles, and music, the caregiver decreases the stress for the child. Information about substance abuse is important to share, but the topics would be better discussed with the child. It is important the adolescent spend time with peers.

The family reports to the nurse that their adolescent always wants to argue, will not participate in family functions, and has poor school grades. What recommendation should the nurse make for an adolescent client who presents with these symptoms? a. Make an appointment with the health care provider. b. Have the child visit the school counselor. c. Supervise homework sessions. d. Encourage participation in sports.

a. Make an appointment with the health care provider. Explanation: Adolescents need to have a thorough physical examination at health maintenance visits to ensure that they are in good physical health. Assessment for depression at these visits includes the assessment for anorexia, insomnia, excessive fatigue and weight loss. In younger adolescents, depression may be manifested not so much by appearing sad, but by behavior problems such as disobedience, temper tantrums, truancy, and running away. Additional signs may be self-destructive behavior, difficulties in school, use of drugs and alcohol, sexual promiscuity or trouble with the legal system. Many adolescents find it hard to be alone, so they seek constant activity as a means of escape.

A teenage girl and her mother are in the office. When the teen uses the restroom, her mother asks you about the changes that Linda is going through. She would like to talk to her about sexuality and its changes but she is unsure of how to do this. As the nurse, what reminders should you give her for when she discusses sex? a. Promote open lines of communication; listen instead of lecture; and share family values. b. Discuss with the teen the experiences that you had so that she can connect on a personal level. c. Encourage her to talk to her peers and teachers in health class. d. Do not initiate any conversation; let the teen come and seek the advice of the parent.

a. Promote open lines of communication; listen instead of lecture; and share family values. Explanation: By promoting open lines of communication between parents and teens, the teenager can go to the parents with problems or questions. There still may be many unanswered questions and parents should be encouraged to listen to their teens rather than lecture them. It is also important for the parents to share family values regarding sexual behavior. Due to the influence of television and movies, many teenagers have an idealized body image or misinformation about sex. In many cases the teenager receives excellent information in health education classes.

The adolescent comes to the clinic seeking information about sexuality concerns. The clinic nurse assures the adolescent that confidentiality and privacy will be maintained unless a life-threatening situation occurs. Maintaining confidentiality demonstrates which nursing goal? Select all that apply. a. an environment where adolescents can be truthful b. inappropriate response because adolescents are minors c. development of a trusting relationship d. concern from parents who pay the office visit bill e. compliance with existing laws

a. an environment where adolescents can be truthful c. development of a trusting relationship e. compliance with existing laws Explanation: Adolescents may seek a health care appointment for an unrelated health concern as a reason to discuss a sexual health question with a health care professional. Reassurance should be given to the adolescent that all questions and concerns will be addressed and will be kept confidential. This is the basis for the nurse-client relationship. All questions and concerns do not involve treatment and therefore do not involve parental consent. Parents may voice concerns because they are responsible for the insurance and billing. The nurse should act as a client advocate and work with the parents to develop a mutual understanding of the situation.

A 13-year-old girl is struggling to accept the new changes that are occurring in her body as a result of puberty. After talking with this client, the nurse recalls that Erikson's primary developmental task of early and mid-adolescence is: a. identity versus role confusion. b. trust versus mistrust. c. autonomy versus shame or doubt. d. intimacy versus isolation.

a. identity versus role confusion. Explanation: According to Erikson, the developmental task in early and mid-adolescence is to form a sense of identity versus role confusion. Adjustment to changes in body image is part of forming this sense of identity. Trust versus mistrust is the developmental task of infancy, autonomy versus shame or doubt is the developmental task of toddlerhood, and intimacy versus isolation is the developmental task of late adolescence.

An adolescent boy of African American descent has been diagnosed with hypertension. Which statement made by the boy indicates to the nurse that additional teaching is needed? a. "My blood pressure should remain less than 130/90 mm Hg." b. "Drinking sodas is not related to my blood pressure." c. "Playing baseball is good exercise for me." d. "My dad has hypertension, so I have to be careful."

b. "Drinking sodas is not related to my blood pressure." Explanation: Hypertension is present if the blood pressure is above the 95th percentile, or 127/81 mm Hg for 16-year-old girls and 131/81 mm Hg for 16-year-old boys for two consecutive readings in different readings. Adolescents who are obese, who are African American, who eat a diet high in salt, or who have a family history of hypertension are most susceptible to developing the condition. Drinking soda regularly increases the amount of sodium intake daily, thus having an impact on the blood pressure.

A teacher refers a student to the school nurse because the student is frequently falling asleep during class. After talking with the student, the nurse is most concerned by which statement by the student? a. "I guess I need to be more careful about my curfew on school nights." b. "I get 7 hours of sleep every night so I don't know why I am so tired." c. "I just can't seem to stay awake during that class because it's boring." d. "My mom keeps telling me to turn off my television when I go to bed."

b. "I get 7 hours of sleep every night so I don't know why I am so tired." Explanation: The average number of hours of sleep that teens require per night is 8.5 to 9.5 due to rapid growth that occurs during these years. Following a curfew and limiting distractions at bedtime can help provide the student with adequate hours of sleep each night.

The nurse is collecting data from a teen being seen for a well-child check. During the interview the teen reports he sleeps about 6 hours per night during the week but is able to sleep 8 to 9 hours on the weekend. What response by the nurse is most appropriate? a. "I am glad to see you are getting the amount of rest you need." b. "Let's talk about ways to increase the amount of rest you get during the week." c. "Sleeping during the weekend to catch up on missed rest is a good thing to do." d. "You would benefit by trying to sleep a little less on the weekends."

b. "Let's talk about ways to increase the amount of rest you get during the week Explanation: It is recommended that teens get 8 to 9.5 hours of sleep per night. Teens who do not get adequate rest during the week often sleep more hours on the weekend. The best practice would be to determine ways to improve daily rest patterns.

An 18-year-old reveals that she has a nipple ring and is looking to get a tattoo in the next few months. What is the most important thing that the nurse can teach her at this time? a. It is not recommended to get the tattoo from your friend in his garage. b. Tattooing carries risks such as infection, disease, and nerve damage. c. Review the safety rules for those who do the tattooing. d. Complications are more likely when they are done on your own.

b. Tattooing carries risks such as infection, disease, and nerve damage. Explanation: The nurse needs to emphasize that tattoos and body piercing can be painful, and carry risks of complications such as infection, blood-borne diseases, keloids and granulomas, allergic reactions, excessive bleeding, nerve damage, or damage to the piercing site. Complications are more likely if they tattoo themselves or have the tattoos done by a friend. The nurse needs to encourage the adolescent to seek the expertise of a trained technician, doctor, or nurse to have the piercing, tattooing, or branding done. There are developed safety rules for those who do piercing and tattoos.

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. a. "Our coach makes us wear sun-protective clothes when we practice outside on the weekends." b. "My mom had melanoma so she always makes me wear a sunscreen with an SPF of 30." c. "My favorite time of day to be outside is the middle of the day, around noon." d. "I only tan before going on spring break to get a base tan so I won't burn." e. "The more exposure and burns I get now will toughen my skin so I won't get skin cancer when I'm older."

c. "My favorite time of day to be outside is the middle of the day, around noon." d. "I only tan before going on spring break to get a base tan so I won't burn." e. "The more exposure and burns I get now will toughen my skin so I won't get skin cancer when I'm older." Explanation: The nurse should further discuss comments that demonstrate incorrect information about sun exposure. Any exposure to tanning beds should be avoided to prevent skin cancer risks. Other risks for skin cancer include being in the sun between the times of 10:00 am and 4:00 pm, and sun exposure and burns during childhood and adolescence. A minimum SPF of 15 should be used, so SPF 30 is good practice, as is wearing sun-protective clothing when outside during the day.

A 15-year-old client's mother comments on the fact that her daughter seems to always choose the opposite of what everyone else wants and that her mood swings are a common occurrence. What statement shows the nurse that the client's mom understands these changes? a. "This is her temperament and we will have to learn how to deal with her." b. "I know that she is doing this because of all the hormones." c. "This is common for this age group and it will get better with time." d. "She will never find anyone to live with her if she acts like this."

c. "This is common for this age group and it will get better with time." Explanation: During middle adolescence, the teenager spends more time ignoring adult authority and becomes more reliant on peer relationships. Adolescents might choose a stance directly opposite that of their parents and use peer support to back their ideas. Mood swings are a common occurrence during the adolescent period. They tend to smooth out and the teen will become more introspective. By late adolescence emotions become more consistent.

A 17-year-old boy chats excitedly with the nurse about his plans for college and a career. He says he has checked out every college in the region and determined which one is the best fit for him and would give him the best career options. The nurse recognizes which developmental aspect in this young man? a. Socialization b. Role confusion c. Formal operational thought d. Puberty

c. Formal operational thought Explanation: The final stage of cognitive development, the stage of formal operational thought, begins at age 12 or 13 years and grows in depth over the adolescent years, though it may not be complete until about 25. This step involves the ability to think in abstract terms and use the scientific method (deductive reasoning) to arrive at conclusions. With the ability to use scientific reasoning, adolescents can plan their future. They can create a hypothesis (What if I go to college? What if I don't?) and think through the probable consequences (In the long run , I'll earn more money; I could begin earning money immediately). This scenario does not pertain to socialization, role confusion, or puberty.

A 15-year-old girl is in the hospital for surgery and is confined to bed. The nurse can tell that the client is nervous about being in the hospital. She tells the nurse that she feels "gross" and "on display" in her hospital gown. What should the nurse do to encourage a sense of autonomy and dignity related to the girl's body image? a. Allow the girl to wear her own clothes, despite hospital policy. b. Assist the girl with using the bedpan to urinate. c. Offer to assist the girl in washing her hair and let her pick the shampoo. d. Brush the girl's hair for her.

c. Offer to assist the girl in washing her hair and let her pick the shampoo. Explanation: Remember when caring for hospitalized adolescents, providing time for self-care, such as shampooing hair, is important to include in an adolescent's nursing care plan. Offering to assist the client in washing her hair and letting her pick the shampoo both encourages a sense of autonomy to the client and offers her dignity related to her body image. Brushing the girl's hair for her and assisting her with using the bed pan for urination do not encourage a sense of autonomy. If it is the hospital's policy to require clients to be dressed in a hospital gown while admitted, the nurse should not allow the girl to wear her own clothes.

Parents comment that their son seemed more coordinated on the basketball floor at 12 years old than he does now at 14. The nurse can include what information in the response? a. Hand-eye coordination is affected negatively by puberty. b. It is more difficult to keep focused at 14 years than at 12. c. Rapid and uneven growth of early adolescence (11 to 14 years) can interfere with coordination. d. This may be a reaction to adult authority.

c. Rapid and uneven growth of early adolescence (11 to 14 years) can interfere with coordination. Explanation: Uneven growth of soft tissues and bones during growth spurts can cause decreased coordination for boys. The age of 14 years is usually the time of peak height velocity (PHV). Mental focus and reaction to adult authority are not causes of poor coordination. Gains in hand-eye coordination are made during puberty and become precise by late adolescence.

The mother of an African-American adolescent voices concern to the nurse because her daughter, "has gotten her period before all of her friends." How should the nurse respond? a. "I will be sure to let the physician know this. We don't want to miss something that may be wrong." b. "How old are most of her friends? Maybe that's the issue instead of it being a sign of something abnormal." c. "Some girls just get their period earlier than others." d. "That must be difficult, but on average African-American girls start their period earlier than other ethnicities."

d. "That must be difficult, but on average African-American girls start their period earlier than other ethnicities." Explanation: Menarche, the first menstrual period, usually begins between the ages of 9 and 15 years (average 12.8 years), but on average African-American girls reach menarche earlier than other ethnicities. This response addresses the mother's concern. The other responses do not address the mother's concern or may lead the mother to think this is an abnormal occurrence.

A client tells the nurse that she has noticed an increase in her weight and fat deposits during the last 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? a. Review dietary measures to assist in controlling weight gain. b. Share what foods can be eaten on a low-fat diet to prevent fat deposits. c. Encourage increased exercise to control weight gain. d. Provide reassurance that these are normal changes.

d. Provide reassurance that these are normal changes. Explanation: Increased fat deposits and weight and height changes are normal as girls begin hormonal changes of puberty. During adolescence, girls are very sensitive about their appearance and constant need for reassurance. Puberty is a period when children are very self-conscious about their overall appearance. Reassurance needs to be provided that increased fat deposits and weight and height changes are normal. Dietary management is indicated if a true weight problem is present. Teenagers should be encouraged to participate in appropriate exercise programs. Dieting issues such as anorexia and bulimia can threaten the health of adolescents.

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? a. They want to successfully complete activities. b. Each child is learning to do things on his or her own. c. They understand and respond to discipline. d. Teens are busy developing their own personal identity. Explanation: According to Erikson, the central task of adolescence is to develop unique personality and identity. The developmental task for the school-age child is to develop a sense of industry, and completing activities builds that feeling of confidence. Erikson's psychosocial developmental task for toddlers is to achieve autonomy (independence) and do things on their own. Learning to speak and to understand and respond to discipline are not developmental tasks, according to Erikson.

d. Teens are busy developing their own personal identity. Explanation: According to Erikson, the central task of adolescence is to develop unique personality and identity. The developmental task for the school-age child is to develop a sense of industry, and completing activities builds that feeling of confidence. Erikson's psychosocial developmental task for toddlers is to achieve autonomy (independence) and do things on their own. Learning to speak and to understand and respond to discipline are not developmental tasks, according to Erikson.