Nokea
A school nurse is talking with a 13-year-old female at her annual health-screening visit. Which of the following comments made by the adolescent should be the nurse's priority to address?
- A. "My parents treat me like a baby sometimes."
- B. "I haven't gotten my period yet, and all my friends have theirs."
- C. "None of the kids at this school like me, and I don't like them either."
- D. "There's a big pimple on my face, and I worry that everyone will notice it."
Correct Answer: C
Rationale: The correct answer is C. The nurse's priority should be to address the adolescent's statement about not liking any kids at school and feeling disliked by others. This suggests potential social isolation, which can impact mental health and well-being. Addressing social relationships is crucial at this age for emotional development. Choices A, B, and D are important but not urgent concerns. Choice A relates to family dynamics, B to physical development, and D to self-image; while these are valid issues, they do not have immediate implications for the adolescent's well-being like the social isolation expressed in choice C.
You may also like to solve these questions
A nurse in an emergency department is caring for an adolescent client who reports being sexually assaulted just prior to admission. Which of the following actions should the nurse take?
- A. Discuss self-defense techniques with the client.
- B. Inform the client that photographs of injuries are required for a police report.
- C. Ask the client to describe the situation.
- D. Give the client a bed bath prior to physical examination.
Correct Answer: C
Rationale: Allowing the client to provide details at their own pace fosters a sense of control.
A nurse is assigning a room to a client who is experiencing a manic episode. Which of the following is the most appropriate room selection?
- A. A room adjacent to the nursing station
- B. A room without a window
- C. A room with dim lighting
- D. A room containing personal belongings
Correct Answer: A
Rationale: A room close to the nursing station allows for close monitoring and quick intervention if necessary.
Where should a nurse assign a client experiencing manic behavior?
- A. Semi-private room across from the day room
- B. Private room in a quiet location
- C. Semi-private room across from the snack area
- D. Shared room near the nursing station
Correct Answer: B
Rationale: The correct answer is B: Private room in a quiet location. This choice is appropriate because a client experiencing manic behavior requires a calm and quiet environment to minimize stimulation and help reduce agitation. Placing the client in a private room can provide the necessary space for the client to calm down and prevent potential triggers for further manic episodes.
Other choices are incorrect:
A: A semi-private room across from the day room may expose the client to increased noise and activity, which can exacerbate manic behavior.
C: A semi-private room across from the snack area may lead to distractions and potential interactions that can escalate the manic behavior.
D: A shared room near the nursing station may not offer the privacy and quiet environment needed for a client experiencing manic behavior to stabilize.
A client commits suicide in an acute mental health facility. Which of the following is the priority intervention for staff following this incident?
- A. Provide professional counseling for staff members.
- B. Change policies for staff observation of clients who are suicidal.
- C. Identify cues in the client's behavior that might have warned them that he was contemplating suicide.
- D. Give the family an opportunity to talk about their feelings.
Correct Answer: C
Rationale: The correct answer is C: Identify cues in the client's behavior that might have warned them that he was contemplating suicide. This is the priority intervention because understanding the warning signs can help prevent future suicides by recognizing and addressing high-risk behaviors. Providing counseling (A) is important but not the immediate priority. Changing policies (B) may be necessary in the long term but does not address the current situation. Giving the family an opportunity to talk (D) is important for support but does not directly address staff intervention.
A nurse in a long-term care facility is caring for a client who has Alzheimer's disease. Which of the following actions should the nurse include in the plan of care?
- A. Post a written schedule of daily activities
- B. Use an overhead loudspeaker to announce events
- C. Provide a consistent daily routine
- D. Allow the client to choose free-time activities
Correct Answer: C
Rationale: The correct answer is C: Provide a consistent daily routine. Individuals with Alzheimer's disease benefit from a structured routine as it helps reduce confusion and anxiety. Consistency in daily activities can enhance familiarity and comfort for the client, promoting a sense of security and predictability. This routine can also aid in maintaining the client's cognitive function and overall well-being.
Incorrect choices:
A: Post a written schedule of daily activities - While this may be helpful, a consistent routine is more effective in providing stability for individuals with Alzheimer's.
B: Use an overhead loudspeaker to announce events - Loud noises and sudden announcements can be overwhelming for individuals with Alzheimer's, causing distress.
D: Allow the client to choose free-time activities - While promoting autonomy is important, too many choices can lead to confusion and difficulty in decision-making for individuals with Alzheimer's.