A 12-year-old girl who has not yet reached menarche comes to the pediatrician’s office for her annual well-child check. As the nurse is weighing and measuring her, the child says emphatically that she does not want to get her period. Which response would be most appropriate for the nurse to make to this child?
“Are you afraid of getting pregnant?”
“Do you think it will hurt?”
“But it’s a good thing, having a period is a part of growing up.”
“What have you heard about it that makes you worried?”
The Correct Answer is D
Choice A reason: Assuming fear of pregnancy may misinterpret the 12-year-old’s concerns, potentially shutting down dialogue. Asking about worries invites her to share specific fears, making this presumptive and incorrect compared to the nurse’s role in exploring the child’s feelings about menstruation openly.
Choice B reason: Suggesting fear of pain narrows the conversation, missing other possible concerns like embarrassment or myths. Asking about worries allows broader exploration, making this limiting and incorrect compared to the nurse’s approach to understanding the girl’s specific fears about getting her period.
Choice C reason: Dismissing the child’s fear by calling periods “good” may invalidate her feelings, discouraging openness. Asking about worries validates concerns, making this dismissive and incorrect compared to the nurse’s role in fostering a supportive dialogue about menstruation with the 12-year-old.
Choice D reason: Asking what the child has heard about periods encourages her to express specific worries, facilitating education and reassurance. This aligns with pediatric nursing communication principles, making it the most appropriate response to address the 12-year-old’s concerns about menarche during the check.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D","E"]
Explanation
Choice A reason: Discussing care options involves clinical judgment, which is the nurse’s responsibility, not delegable to family. Providing comfort tasks like swabs or pads is appropriate, making this incorrect, as it involves professional decision-making unsuitable for family delegation in the adolescent’s care.
Choice B reason: Keeping medical equipment like a blood pressure cuff involves monitoring, a nursing task, not delegable to family. Comfort tasks like providing swabs or pillows are suitable, making this incorrect, as it requires clinical skills beyond family’s role in the terminally ill adolescent’s care.
Choice C reason: Supplying mouth swabs for lip moistening is a simple comfort task family can perform, promoting involvement and patient comfort. This aligns with pediatric palliative care delegation, making it a correct intervention to delegate to family for the terminally ill adolescent’s care.
Choice D reason: Providing disposable pads for hygiene is a non-clinical task family can manage, supporting dignity and comfort. This aligns with family involvement in palliative care, making it a correct intervention to delegate for the terminally ill adolescent’s care in the hospital setting.
Choice E reason: Supplying pillows for repositioning is a comfort-focused task family can handle, enhancing the adolescent’s well-being. This aligns with pediatric palliative care principles, making it a correct intervention to delegate to family members for the terminally ill adolescent’s hospital care.
Correct Answer is ["A","D","E"]
Explanation
Choice A reason: Normal heart rate and respirations indicate reduced physiological stress from pain, supporting effective medication in a terminally ill child. This aligns with pediatric pain assessment criteria, making it a correct assessment to document as evidence of successful pain relief post-medication administration.
Choice B reason: Withdrawing from the environment suggests ongoing distress or pain, not relief. Normal vitals and low pain scores indicate effectiveness, making this incorrect, as it reflects a negative outcome rather than supporting successful pain management in the terminally ill child’s evaluation.
Choice C reason: A flexed position may indicate persistent pain or discomfort, not relief. Sleeping or low pain scores better demonstrate effectiveness, making this incorrect, as it does not support the medication’s success in alleviating pain in the terminally ill client during the assessment.
Choice D reason: Verbalizing a 1 on the pain scale directly indicates minimal pain, confirming the medication’s effectiveness in a terminally ill child. This aligns with pediatric pain management standards, making it a correct assessment to document as evidence of successful pain relief post-administration.
Choice E reason: Quietly sleeping on the parent’s lap suggests comfort and pain relief, a positive sign in a terminally ill child. This aligns with behavioral pain assessment in pediatrics, making it a correct observation to document as evidence of effective medication for pain management.
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