A 15-year-old adolescent is brought to the clinic by a parent who is concerned about recent changes in behavior. The parent reports that the teen has become withdrawn, irritable, has declining grades, and has started hanging out with a new group of friends. The nurse suspects possible substance use. What is the priority nursing intervention?

Recommend immediate drug testing to confirm substance use.

Reassure the parent that behavioral changes are a normal part of adolescence.

Tell the adolescent that substance use can lead to serious consequences and should be avoided.

Ask the adolescent directly about substance use in a private, non-judgmental manner.

Answer and Explanation

The Correct Answer is D

Rationale:

A. Recommend immediate drug testing to confirm substance use: While drug testing may be part of the assessment process, it is not the first priority. Establishing trust and gathering history from the adolescent is essential before moving to diagnostic measures.

B. Reassure the parent that behavioral changes are a normal part of adolescence: Although moodiness and peer changes can occur in adolescence, the presence of multiple risk factors, withdrawal, irritability, poor academic performance, requires further assessment rather than reassurance.

C. Tell the adolescent that substance use can lead to serious consequences and should be avoided: Providing education about risks is important, but doing this before assessing the situation may shut down communication and make the teen defensive.

D. Ask the adolescent directly about substance use in a private, non-judgmental manner: This allows the nurse to gather accurate information in a confidential environment, promoting trust and honest disclosure which are critical for further planning and intervention.

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Correct Answer is D

Explanation

Rationale:

A. The infant's eye appears to be protruding: Protrusion of the eye, or proptosis, is more often linked to orbital tumors, severe infections, or trauma rather than retinoblastoma. Retinoblastoma primarily affects the retina inside the eye, not surrounding orbital structures.

B. The infant tugs and pulls at one ear: Ear pulling is more commonly associated with otitis media or ear discomfort. This behavior is not connected to retinoblastoma and would not be expected in a history related to an intraocular tumor.

C. The infant always keeps her eyes tightly closed: Persistent eye closure could be a sign of photophobia, eye irritation, or pain from corneal abrasions or infections, but it is not the hallmark presentation of retinoblastoma.

D. One pupil appears white: A white reflex in the pupil, known as leukocoria, is a classic finding in retinoblastoma. Parents may notice this when light shines in the child’s eye, where one pupil appears white instead of the normal red reflex.

A. Administering thyroid hormone replacement. B. Regular blood glucose monitoring and insulin therapy. C. High-protein diet to promote growth. D. Lifelong glucocorticoid (hydrocortisone) and mineralocorticoid (fludrocortisone) replacement therapy.

Correct Answer is D

Explanation

Rationale:

A. Administering thyroid hormone replacement: Thyroid hormone therapy is indicated for hypothyroidism, not congenital adrenal hyperplasia. CAH is related to impaired adrenal hormone production, so replacing thyroid hormone would not address the underlying issue.

B. Regular blood glucose monitoring and insulin therapy: This is a mainstay in the management of diabetes mellitus, not CAH. While adrenal insufficiency can influence glucose regulation, insulin therapy is not a primary treatment unless there is coexisting diabetes.

C. High-protein diet to promote growth: Adequate nutrition is important for all children, but a high-protein diet alone does not correct the hormonal deficiencies in CAH. Without proper hormone replacement, growth and development will still be impaired.

D. Lifelong glucocorticoid (hydrocortisone) and mineralocorticoid (fludrocortisone) replacement therapy: This is the cornerstone of CAH management, replacing the deficient cortisol and aldosterone to maintain electrolyte balance, blood pressure, and normal metabolism.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is completing a health history with the parents of a 6-month-old infant with retinoblastoma. Which symptom should the nurse expect that the parents have observed?

Correct Answer is D

Explanation

Which of the following is essential in the lifelong management of a child with congenital adrenal hyperplasia (CAH)?

Correct Answer is D

Explanation

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