NURSING 4710 Adolescent

NURSING 4710 Adolescent Question 1 See full question A nurse is caring for an adolescent who has been diagnosed with a spleen laceration resulting from a skateboard accident. Which nursing diagnosis should be the highest priority? You Selected:  Deficient fluid volume (hemorrhage) Correct response:  Deficient fluid volume (hemorrhage) Explanation: Deficient fluid volume(hemorrhage) is of highest priority because the spleen is a vascular organ. Laceration may lead to hemorrhage. Risk for injury related to unsteady gait isn't indicated in this situation. Disturbed body image isn't a concern because the adolescent doesn't have a visible injury. Although the adolescent may be placed on bed rest for 5 to 7 days, Impaired physical mobility isn't the priority nursing diagnosis. Question 2 See full question The parents of an adolescent girl have recently learned that their daughter has a terminal illness. At first, as they try to cope, they display avoidance behaviors. Then they demonstrate behaviors that indicate possible acceptance of the diagnosis. Which behavior indicates acceptance? You Selected:  Expression of feelings, such as sorrow and anger, about the girl's condition Correct response:  Expression of feelings, such as sorrow and anger, about the girl's condition Explanation: The ability to express feelings and relate them to the diagnosis is the first step in accepting the situation. Failing to recognize the seriousness of the girl's condition despite physical evidence, intellectualizing about the illness in areas unrelated to the girl's condition, and avoiding staff, family members, or the girl herself are all avoidance behaviors that represent a parent's inability to cope with the situation. Question 3 See full question Which child should the nurse identify as being most at risk for an episode of major depression? You Selected:  a 14-year-old female who recently moved to a new school after her parents' divorce Correct response:  a 14-year-old female who recently moved to a new school after her parents' divorce Explanation: Children who experience serious losses, especially multiple losses, such as old friends or a parent, are more at risk for depression. Girls also are at greater risk than boys during the adolescent years. Question 4 See full question An adolescent woman, whose family is living in a cult, ran away from the group’s compound to her aunt’s house. The aunt brought the girl to the emergency department after finding multiple knife cuts in various stages of healing on the girl’s body. She is admitted to the unit because of many trauma-related symptoms. What actions should the nurse take? Select all that apply. You Selected:  Teach her ways to control self-destructive behaviors such as suicide attempts, self-mutilation, and rage outbursts.  Help her process her emotions and memories as she is willing to share these.  Teach her emotion management skills to help her deal with her "normal reactions to an abnormal situation." Correct response:  Teach her emotion management skills to help her deal with her "normal reactions to an abnormal situation."  Assess her for other possible injuries, pregnancy, and sexually transmitted infections.  Teach her ways to control self-destructive behaviors such as suicide attempts, self-mutilation, and rage outbursts.  Obtain a sample for a urine drug screen and routine urinalysis.  Help her process her emotions and memories as she is willing to share these. Explanation: Controlling self-destructive behaviors is a priority, but developing emotion management skills and processing emotions and memories are also important. Assessing for injuries, pregnancy, sexually transmitted infections, and drugs in her system is important due to the fact that most cults foster sex and pregnancy in young teens and often use drugs to achieve compliance from the girls. It is not appropriate to ask the client to share her experiences in a group of teens. It could be more damaging to the client unless the other teens are also trauma/torture survivors. Question 5 See full question A 16-year-old client requires chemotherapy for leukemia. The client’s parents support the physician’s recommendation, but the client is refusing treatment. What is the nurse’s role in this situation? You Selected:  Request that the physician thoroughly explain the benefits and consequences of treatment to the client. Correct response:  Request that the physician thoroughly explain the benefits and consequences of treatment to the client. Explanation: The nurse has a responsibility to the client and should act as an advocate. This may include notifying the physician of the client’s decision and ensuring that the client understands the information that has been given by the doctor in order to make an informed decision. The other options do not demonstrate the nurse's understanding of client advocacy and the client’s right to choice. Question 1 See full question The nurse manager in the emergency department (ED) is conducting an in-service for the nursing staff about screening clients for suicide. One of the nurses states, "Questioning adolescents about suicide will only increase their thinking about self-harm, and they would not admit it to me anyhow." How should the nurse manager respond? You Selected:  "It is a myth that talking about suicide leads to suicide attempts. Adolescents will disclose suicidal thoughts when asked directly." Correct response:  "It is a myth that talking about suicide leads to suicide attempts. Adolescents will disclose suicidal thoughts when asked directly." Explanation: It is important to assess clients in the ED for suicide risk so that those with the potential can receive help prior to discharge. Many visitors to the ED have no other source for health care. It is a myth that talking about suicide will cause young people to think about suicide, and evidence exists that they will talk about suicide if asked directly. Assessing adults only because they will be more honest is an incorrect assumption. Limiting the assessment of suicide risk only to adolescents with psychiatric diagnoses falsely assumes that other young people are not at risk for suicide. Questioning the parents about their adolescent’s suicide risk may be an unreliable method because the parents may not be aware that suicide risk is present. ....Continued.....