The nurse is caring for a chronically ill adolescent client.
What can the nurse do to maintain stimulation and support the client's sense of identity while hospitalized?
Explain food choices appropriate to the prescribed diet.
Plan activities around scheduled rest periods.
Encourage communicating with friends through social media.
Teach the name and indications for use of all medications.
The Correct Answer is C
Choice A rationale
Explaining food choices appropriate to the prescribed diet is important for health education and adherence to a treatment plan. However, this action primarily addresses physiological needs and compliance. While it involves the client, it does not specifically promote an adolescent's sense of identity or provide external stimulation vital for a person in this developmental stage, which heavily relies on peer interaction for self-definition and engagement.
Choice B rationale
Planning activities around scheduled rest periods supports physical recovery and compliance with medical necessity for rest. This intervention addresses energy conservation and the physiological needs of the chronically ill client. However, it does not actively encourage social interaction, personal expression, or engagement with the outside world, all of which are critical components for maintaining the sense of self and developmental needs of an adolescent.
Choice C rationale
Encouraging communicating with friends through social media is the most effective way to maintain stimulation and support the adolescent's sense of identity. Adolescents derive their self-concept heavily from peer interaction and social networking. Facilitating this contact reduces feelings of isolation, maintains social roles, and allows them to participate in their normal developmental tasks, thus bolstering their identity and emotional well-being despite hospitalization.
Choice D rationale
Teaching the name and indications for use of all medications is a key component of client education and fosters autonomy and compliance. While knowing about their treatment plan empowers the client, this task is focused primarily on health literacy and adherence. It does not provide the external stimulation or peer connection that is fundamentally necessary for an adolescent to sustain their identity and mitigate the psychological toll of chronic illness and hospitalization.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Obtaining a full set of vital signs is a crucial part of the secondary assessment, but it follows the primary assessment (ABCs) and the initial rapid assessment of neurological status (AVPU or level of consciousness). The priority immediately after ensuring ABCs is to determine the child's immediate neurological status and responsiveness, which guides subsequent interventions for stabilizing the child.
Choice B rationale
While pain management is extremely important and should be addressed promptly, it is not the immediate priority following the primary ABC assessment. Assessing the level of consciousness (D in the 'ABCDE' trauma/emergency assessment) is the next vital step, as changes in neurological status can indicate immediate life threats like intracranial pressure or hypoxia.
Choice C rationale
Removing the child's clothing (Exposure in the 'ABCDE' approach) is performed to conduct a full physical examination and check for injuries, but it must be done after the immediate life threats (ABCs and initial Disability/LOC) are addressed. This step is also crucial for preventing hypothermia, making temperature regulation important after exposure, but not the first step after ABCs.
Choice D rationale
Assessing the level of consciousness (LOC) is the essential next step after the primary survey (Airway, Breathing, Circulation) in pediatric emergency care, corresponding to the 'D' (Disability) in the ABCDE approach. A rapid assessment, often using the AVPU scale (Alert, Voice, Pain, Unresponsive), provides an immediate gauge of the child's neurological function and helps detect life-threatening issues like hypoxia or severe hypoglycemia.
Correct Answer is ["75"]
Explanation
Step 1 is: Calculate the volume of Ceftriaxone to administer. 1500 mg ÷ (40 mg ÷ 1 mL) = 1500 mg × (1 mL ÷ 40 mg) = 37.5 mL.
Step 2 is: Calculate the infusion rate in mL/hr. 37.5 mL ÷ 30 min × 60 min ÷ 1 hr = 37.5 mL × 2 = 75 mL/hr. The infusion rate is 75.
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