A nurse is caring for an adolescent who is scheduled for insertion of an intrauterine device. Which of the following actions should the nurse take?
Encourage the adolescent to wait to ask questions about the device until after its insertion.
Call the adolescent's guardian to obtain verbal consent prior to the procedure.
Reschedule the procedure until the client's guardian provides written consent.
Witness the adolescent's signature on the consent form.
The Correct Answer is D
A. "Encourage the adolescent to wait to ask questions about the device until after its insertion." The adolescent should be encouraged to ask questions before the procedure to ensure informed consent and understanding.
B. "Call the adolescent's guardian to obtain verbal consent prior to the procedure." In many areas, adolescents can provide consent for reproductive health services, including contraception, without parental consent.
C. "Reschedule the procedure until the client's guardian provides written consent." Most states and healthcare policies allow minors to consent to birth control procedures without requiring parental involvement.
D. "Witness the adolescent's signature on the consent form." The nurse should witness and document the adolescent’s informed consent, as they have the right to make decisions regarding their reproductive health.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. "Perform a sterile dressing change 8 hr after the procedure." The initial dressing should be left in place for at least 24 hours, and any dressing changes should be performed per facility protocol.
B. "Keep the affected extremity straight for 4 hr." After a femoral venous cardiac catheterization, the child should keep the affected extremity straight for about 4 to 6 hours to prevent bleeding or hematoma formation at the insertion site.
C. "Assess the pulses above the catheterization site." The pulses below the site (distal pulses) should be assessed, not above. This is important to check for adequate circulation and potential complications such as clot formation or arterial obstruction.
D. "Maintain NPO status for 24 hr following the procedure." The child should typically resume oral intake as soon as they are fully awake and able to tolerate fluids, usually within a few hours post-procedure.
Correct Answer is []
Explanation
Condition Most Likely Experiencing: Crohn's disease
Actions to Take:
- Record dietary intake
- Provide a gluten-free diet.
Parameters to Monitor:
- Albumin level.
- Hemoglobin level.
Rationale:
Crohn’s Disease- Positive stool occult blood and positive leukocytes suggest intestinal inflammation and bleeding, which are characteristic of Crohn’s disease. Elevated C-reactive protein (CRP) (3.2 mg/dL) and WBC count (13,000/mm³) indicate inflammation and infection, common in Crohn’s disease flare-ups. Low albumin (3.4 g/dL) suggests malabsorption and protein loss, which occurs in Crohn’s disease due to chronic inflammation and poor nutrient absorption.
Appendicitis – Usually presents with localized right lower quadrant (RLQ) pain, fever, nausea, vomiting, and abdominal rigidity. The patient does not have classic signs of appendicitis.
Peptic Ulcer Disease (PUD) – Typically associated with H. pylori infection (negative in this case) and does not usually cause elevated CRP and WBC.
Celiac Disease – Would not cause elevated inflammatory markers (CRP, WBC) or stool occult blood.·
Record dietary intake.Nutritional deficiencies (e.g., low albumin) are common in Crohn’s disease. Keeping a food diary helps identify trigger foods that exacerbate symptoms.
Provide a gluten-free diet. While gluten-free diets are primarily for celiac disease, some Crohn’s disease patients may benefit from avoiding gluten and other inflammatory foods. Low-residue, high-protein diets are often recommended to reduce intestinal irritation and promote healing.
Administer an enema. Contraindicated in Crohn’s disease, as enemas can worsen inflammation and irritate the bowel.
Prepare for surgery. Surgery is not the first-line treatment for Crohn’s disease. It is only considered for severe complications (e.g., strictures, fistulas, or perforation).
Albumin level. Low albumin suggests malabsorption and protein loss, which should be monitored to assess nutritional status.
Hemoglobin level. Anemia (Hgb 11 g/dL, Hct 33%) suggests chronic blood loss from inflammation. Monitoring hemoglobin helps assess disease progression and response to treatment.
Abrupt decrease in pain level. This would be a concern for bowel perforation rather than an indicator of improvement in Crohn’s disease.
Abdominal rigidity. Not a typical assessment parameter for Crohn’s disease, but more relevant for appendicitis or peritonitis
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