A school counselor refers a teen for evaluation after she gives away personal belongings and writes about death in her journal.
What is the nurse's priority action?

Choice A rationale

Providing a high-protein diet is beneficial for tissue repair and overall healing, as proteins are essential building blocks for cells and enzymes involved in the inflammatory and reparative processes. However, this intervention is secondary to addressing the underlying infection. Nutritional support optimizes recovery but does not directly eliminate the bacterial pathogen.

Choice B rationale

Encouraging weight-bearing on the affected limb is contraindicated in acute osteomyelitis. This action could exacerbate inflammation, increase pain, and potentially lead to pathological fractures or further dissemination of the infection within the bone, compromising structural integrity and delaying healing. Rest is crucial for minimizing stress on the compromised bone.

Choice C rationale

Administering IV antibiotics as prescribed is the priority intervention because osteomyelitis is a severe bacterial infection of the bone. Intravenous administration ensures high systemic concentrations of antibiotics, reaching the infected bone tissue efficiently to eradicate the pathogen, prevent further bone destruction, and reduce the risk of systemic complications like sepsis.

Choice D rationale

Applying heat packs to the affected area might provide some symptomatic relief from pain by increasing blood flow, but it is not a primary intervention for osteomyelitis. Heat can potentially increase swelling and may not be effective in reaching the deep-seated infection within the bone. Direct antimicrobial therapy is paramount for resolution.

Choice A rationale

Providing privacy and factual information is crucial for adolescents navigating puberty. Privacy allows for open discussion without embarrassment, and accurate information addresses concerns, corrects misinformation, and normalizes physical changes. This empowers the adolescent to understand and accept their developing body.

Choice B rationale

Telling an adolescent that body changes are not important dismisses their valid concerns during a highly sensitive developmental period. Adolescence is marked by significant physical and psychological transformations, and body image is central to self-esteem and identity formation.

Choice C rationale

Discouraging discussions about body image can lead to internalized anxiety, self-consciousness, and a lack of accurate information. Open communication about body image concerns is vital for adolescents to develop a healthy self-perception and address any potential negative body image issues.

Choice D rationale

While peer support is valuable, suggesting an adolescent speak only with peers can limit their access to accurate information and professional guidance. Peers may share misinformation or reinforce unhealthy perspectives. A balanced approach involves parental/guardian and healthcare professional involvement alongside peer support.