A nurse is caring for an adolescent client who is scheduled for surgery. Which of the following actions should the nurse take to prepare the child based on their developmental stage?
Discuss how the procedure might affect the client's appearance.
Avoid involving the client in decisions regarding treatment.
Emphasize that the procedure is not a punishment.
Keep equipment out of the client's sight.
The Correct Answer is A
Choice A rationale:
Adolescents are at a stage of development where body image and appearance are of significant importance. Discussing how the procedure might affect the client's appearance allows the nurse to address the adolescent's concerns and fears related to changes in their body. This can help alleviate anxiety and promote a sense of control over the situation, fostering a more positive psychological response to the surgery.
Choice B rationale:
Avoiding involving the client in decisions regarding treatment (Choice B) would not be appropriate for an adolescent. Adolescents are at a stage where they are developing autonomy and decision-making skills. Excluding them from decisions about their treatment could lead to feelings of powerlessness and hinder their sense of control.
Choice C rationale:
Emphasizing that the procedure is not a punishment (Choice C) might be suitable for younger children who might associate medical procedures with punishment. However, adolescents typically do not perceive medical procedures as punishments, so this explanation may not address their specific concerns.
Choice D rationale:
Keeping equipment out of the client's sight (Choice D) might be more relevant for younger children who might be frightened by medical equipment. Adolescents are generally better able to comprehend and cope with the presence of medical equipment. Open communication about the procedure and addressing their concerns directly would be more beneficial.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Decreased white blood cells (WBCs) in cerebrospinal fluid (CSF) would not support the diagnosis of bacterial meningitis. In bacterial meningitis, the presence of bacteria triggers an inflammatory response, leading to an increase in WBCs in the CSF (pleocytosis).
Choice B rationale:
Elevated glucose levels in CSF would actually be more consistent with viral rather than bacterial meningitis. In bacterial meningitis, glucose levels are typically decreased due to the high metabolic demands of bacteria on the glucose present in the CSF.
Choice C rationale:
Elevated total protein in cerebrospinal fluid (CSF) is indicative of inflammation and disruption of the blood-brain barrier. Bacterial meningitis causes an intense inflammatory response, leading to an increase in total protein in the CSF.
Choice D rationale:
Decreased pressure in the CSF would not be a characteristic finding in bacterial meningitis. In fact, bacterial meningitis often leads to an increase in CSF pressure due to the inflammation and accumulation of inflammatory cells and proteins.
Correct Answer is B
Explanation
Choice A rationale:
The Rotavirus vaccine is typically administered to infants, usually starting at 2 months of age, to protect against severe diarrhea and vomiting caused by rotavirus infection. However, the child in question is 11 years old, and the rotavirus vaccine is not recommended for administration at this age. The vaccine's protection window is within the infant and early childhood period, and the child would likely have received this vaccine earlier.
Choice B rationale:
Haemophilus influenzae type b (Hib) Hib vaccine is recommended as a series of doses to protect against Haemophilus influenzae type B infection, which can lead to severe illnesses like meningitis and pneumonia. While the child may have received this vaccine in infancy, a booster dose is often recommended around age 11 to ensure ongoing protection. This choice is correct for the given age group.
Choice C rationale:
Hepatitis A Hepatitis A vaccine is typically administered in two doses, with the first dose given at age 1 and the second dose administered at least 6 months later. The child in question is 11 years old, and assuming the child received the vaccine as per the standard schedule, there would be no need to administer this vaccine again.
Choice D rationale:
Human papillomavirus (HPV) HPV vaccine is recommended for adolescents to protect against several strains of the human papillomavirus that can lead to various cancers later in life. It's usually administered in a series of doses starting around age 11 or 12. However, the prompt states that the child is already up-to-date with current immunizations, and if the child received the HPV vaccine at the appropriate age, there would be no need for another dose at this time.
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