A nurse is talking with a 13-year-old female client who is having her annual health-screening visit. Which of the following comments by the client should concern the nurse?
"My parents treat me like a baby sometimes."
"There's a pimple on my face, and I worry that everyone will notice it."
"I start taking ibuprofen a few days before my period starts."
"None of the kids at my school like me, and I don't like them either."
The Correct Answer is D
A. "My parents treat me like a baby sometimes." This statement reflects a common adolescent feeling of striving for independence and experiencing frustration when treated as a child. It is a normal part of adolescent development and not a cause for immediate concern.
B. "There's a pimple on my face, and I worry that everyone will notice it." Concern about appearance is typical for adolescents due to the increased focus on body image and peer perception. This statement is a normal expression of adolescent self-consciousness.
C. ``I start taking ibuprofen a few days before my period starts." Using ibuprofen preemptively for menstrual cramps is a reasonable self-care practice for adolescents experiencing menstrual discomfort. This statement does not indicate any immediate health concern.
D. "None of the kids at my school like me, and I don't like them either." This statement indicates social isolation and potential issues with peer relationships, which can be a red flag for emotional distress or depression. It may suggest that the adolescent is experiencing significant difficulties in their social life that could lead to more serious mental health concerns.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. The parent reports the child will not keep the arm elevated on the pillow: Not a priority. While elevation is important, it is not immediately concerning.
B. The fingers on the right hand have a capillary refill of 4 seconds: Correct. A capillary refill time of more than 2 seconds indicates poor perfusion, which can be a sign of compartment syndrome, a serious complication.
C. The fingertips of the right hand are swollen and bruised: Concerning, but swelling and bruising can be normal post-injury. Immediate concern is perfusion.
D. The child is not attempting to move her right arm or fingers: Concerning, but can be due to pain or fear. Poor perfusion (B) is a more immediate threat.
Correct Answer is A
Explanation
A. Initiate droplet precautions. Pertussis (whooping cough) is transmitted via respiratory droplets. Droplet precautions are necessary to prevent the spread of the disease through coughs or sneezes.
B. Initiate a protective environment. A protective environment is used for patients with severe immunocompromised conditions to protect them from infections, not to prevent the spread of respiratory infections like pertussis.
C. Initiate contact precautions. Contact precautions are used for infections spread by direct or indirect contact with the patient or their environment, such as MRSA. Pertussis is spread by droplets, not by contact.
D. Initiate airborne precautions. Airborne precautions are for diseases that are spread through airborne particles, such as tuberculosis or measles. Pertussis is not airborne but spread through larger respiratory droplets.
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