A 14-year-old male is admitted after a sports injury.
He appears withdrawn and avoids eye contact with staff. What is the best nursing approach?
Offer privacy and allow the patient to express himself gradually.
Encourage him to discuss his emotions with his parents.
Focus only on physical care to avoid overwhelming him.
Assign him to a shared room to improve socialization.
The Correct Answer is A
Choice A rationale
Offering privacy and allowing gradual self-expression respects the adolescent's developmental stage, which often includes a need for autonomy and fear of judgment. Providing a non-threatening environment can reduce anxiety and build trust, fostering a sense of security that encourages the patient to open up when they feel ready, without feeling pressured or overwhelmed.
Choice B rationale
Encouraging immediate discussion with parents might be premature and perceived as a lack of understanding by the adolescent. Adolescents often value peer relationships and may find it difficult to express sensitive emotions to parents, especially after a traumatic event like an injury. This approach could increase their withdrawal and reluctance to communicate.
Choice C rationale
Focusing solely on physical care neglects the psychological and emotional needs of the adolescent, which are crucial for holistic recovery. Emotional distress can hinder physical healing and overall well-being. Avoiding emotional support can make the patient feel invalidated and isolated, potentially prolonging their withdrawal and emotional distress.
Choice D rationale
Assigning a withdrawn adolescent to a shared room without prior assessment or consent can exacerbate their anxiety and discomfort. While socialization is important, forcing it upon a patient who is already withdrawn can be counterproductive, potentially leading to increased stress and a further retreat into themselves rather than improving their social engagement.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
A weight gain of 25 to 35 pounds is the general recommendation for women who begin pregnancy with a normal body mass index (BMI) of 18.5 to 24.9. Since the client has a BMI of 26.5, she falls into the overweight category, and her recommended weight gain range is different to optimize maternal and fetal outcomes.
Choice B rationale
For pregnant individuals who are classified as overweight, defined by a BMI of 25.0 to 29.9, the recommended total weight gain during pregnancy is 15 to 25 pounds (approximately 6.8 to 11.3 kg). This guideline aims to minimize risks such as gestational diabetes, preeclampsia, and macrosomia while ensuring adequate fetal growth.
Choice C rationale
A weight gain of 11 to 20 pounds is the recommendation for pregnant individuals who are classified as obese, with a BMI of 30.0 or greater. This client's BMI of 26.5 places her in the overweight category, not obese, necessitating a different target range for gestational weight gain to promote healthy outcomes.
Choice D rationale
While a healthy diet is crucial during pregnancy, the exact amount of weight gained does matter for both maternal and fetal health outcomes. Excessive or insufficient weight gain can lead to various complications, including gestational diabetes, preeclampsia, preterm birth, and abnormal fetal growth, thus specific weight gain targets are important.
Correct Answer is D
Explanation
Choice A rationale
An alpha-fetoprotein (AFP) test is a blood test that measures the levels of AFP in the maternal serum. This test does not require any specific dietary restrictions, such as fasting. Therefore, advising the client to abstain from food or drink for 8 hours before the test is not based on physiological necessity for accurate AFP measurement.
Choice B rationale
Test results are influenced by various factors, including gestational age, multiple pregnancies, and certain fetal anomalies. While chronic illnesses can impact overall health, they do not directly determine the outcome of an AFP screening test, which primarily assesses the risk of neural tube defects or chromosomal abnormalities.
Choice C rationale
An AFP test is a simple blood draw and is not an invasive procedure. Therefore, there is no physiological need for bed rest following the test. Clients can resume their normal activities immediately after the blood sample is collected, as there are no associated post-procedure complications requiring immobility.
Choice D rationale
The AFP test is a screening tool, meaning it identifies individuals who may be at an increased risk for certain conditions, such as neural tube defects or Down syndrome. It does not provide a definitive diagnosis. Abnormal screening results necessitate further diagnostic testing, such as amniocentesis or high-resolution ultrasound, for confirmation.
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