A nurse is performing a physical assessment for a 13-year-old adolescent. Which of the following actions should the nurse take?

Have the child bend forward at the waist and check for asymmetry of the scapula.

Auscultate the abdomen for at least 1 min if bowel sounds are absent.

Use the FACES scale to assess pain.

Observe abdominal movement to determine the respiratory rate.

Answer and Explanation

The Correct Answer is A

A. "Have the child bend forward at the waist and check for asymmetry of the scapula." This maneuver is known as the Adam's forward bend test and is used to screen for scoliosis, which commonly appears during adolescence.
B. "Auscultate the abdomen for at least 1 min if bowel sounds are absent." If bowel sounds are absent, the nurse should listen for at least 5 minutes in each quadrant before concluding they are truly absent.
C. "Use the FACES scale to assess pain." The FACES scale is typically used for younger children (3-7 years old). Adolescents can usually use a numeric rating scale (0-10) for pain assessment.
D. "Observe abdominal movement to determine the respiratory rate." Abdominal breathing is characteristic of infants and younger children. In adolescents, the nurse should observe chest movement to assess respiratory rate.

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Correct Answer is A

Explanation

A. "Wear a face mask when working within 3 feet of a child who is infected." Influenza spreads through droplets, so wearing a face mask within 3 feet of an infected child helps prevent transmission.
B. "Administer antibacterial medication within 24 hr of the onset of symptoms." Influenza is caused by a virus, not bacteria, so antibacterial medications (antibiotics) are not effective. Antiviral medications (e.g., oseltamivir) may be given within 48 hours of symptom onset.
C. "Children should be considered infectious for 14 days after the onset of symptoms." . Children with influenza are most contagious 1 day before symptoms appear and up to 5 to 7 days after onset.
D. "Administer the influenza vaccine every 6 months." The influenza vaccine is given annually (once per year), not every 6 months.

A. "I wish I knew what I did to cause my child to be sick." B. "I saw on the internet that there's a new treatment option." C. "I don't want my family to know about my child's diagnosis." D. "I am not sure how to care for my dying child."

Correct Answer is B

Explanation

A. "I wish I knew what I did to cause my child to be sick." This statement reflects self-blame and guilt, which are signs of poor coping.
B. "I saw on the internet that there's a new treatment option." This demonstrates hope and proactive coping, as the guardian is seeking information and exploring options.
C. "I don't want my family to know about my child's diagnosis." Avoiding support from family may indicate denial or isolation, which are maladaptive coping strategies.
D. "I am not sure how to care for my dying child." Expressing uncertainty about caregiving suggests distress and a need for additional support and education, rather than positive adjustment.

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Body system	Findings
Respiratory	Respiratory rate 264min
Cardiovascular	Heart rate 112/min Capillary refill 4 seconds
Gastrointestinal	Hyperactive bowel sounds
Integumentary	Diaper area reddened Extremities cool Reports no tears
Neurologic	Lethargic

A nurse is performing a physical assessment for a 13-year-old adolescent. Which of the following actions should the nurse take?

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A nurse is performing a physical assessment for a 13-year-old adolescent. Which of the following actions should the nurse take?