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He appears withdrawn and avoids eye contact with staff.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Assigning a withdrawn adolescent to a shared room without prior assessment or consent can exacerbate their anxiety and discomfort. While socialization is important, forcing it upon a patient who is already withdrawn can be counterproductive, potentially leading to increased stress and a further retreat into themselves rather than improving their social engagement.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 C
Explanation
Choice A rationale
Phalen's Maneuver is a diagnostic test used to assess for carpal tunnel syndrome. It involves sustained wrist flexion, which increases pressure within the carpal tunnel, exacerbating median nerve compression symptoms such as tingling and numbness in the hand. This test is unrelated to spinal curvature assessment.
Choice B rationale
The Romberg Test evaluates proprioception and cerebellar function, assessing a person's ability to maintain balance with eyes closed. It helps identify neurological deficits affecting balance and coordination but does not involve direct assessment of spinal alignment or curvature, thus it is not used for scoliosis screening.
Choice C rationale
Adam's Forward Bend Test is the primary method used during scoliosis screening. It involves the individual bending forward at the waist with feet together and arms hanging loosely. This position makes any asymmetry or prominence of the ribs or spine more visible, indicating a potential spinal curvature.
Choice D rationale
Lasegue's Sign Test, also known as the Straight Leg Raise Test, is used to detect nerve root irritation, typically associated with sciatica or herniated lumbar discs. It involves passively raising the straightened leg of a supine patient to elicit pain, indicating nerve compression. This test is not for scoliosis screening.
Correct Answer is B
Explanation
Choice A rationale
While journaling can be a therapeutic outlet, encouraging it as a priority action in this situation could be detrimental. The teen's writings about death and giving away belongings are strong indicators of potential suicidal ideation, which necessitates immediate assessment and intervention for safety rather than emotional expression without prior safety assurance.
Choice B rationale
Giving away personal belongings and writing about death are significant warning signs of suicidal ideation. The nurse's priority action is to immediately assess for suicide risk, determine the level of intent and plan, and initiate appropriate safety measures to prevent harm. This direct intervention is crucial for ensuring the teen's immediate well-being.
Choice C rationale
Notifying the teen's teacher might be a subsequent step in a comprehensive safety plan, but it is not the immediate priority. The teacher's role is to monitor behavior within the school setting, but they are not equipped to perform a comprehensive suicide risk assessment or implement immediate safety measures like a nurse.
Choice D rationale
Providing information on grief support is not the priority action when there are direct indicators of potential suicide risk. While loss can contribute to suicidal thoughts, the immediate concern is the risk to the teen's life, which requires direct assessment for suicidal intent and the implementation of safety protocols, not generalized grief support.
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