A nurse is assisting with the care of an adolescent. Which of the following statements should the nurse identify as high-risk behaviors?

I participate in physical activities 3 times per week

I use sunscreen with an SPF of 10.*

I limit playing video games to 3 hours per day."

I have had sexual relations, but did not get the HPV vaccine."

Answer and Explanation

The Correct Answer is D

A) I participate in physical activities 3 times per week: Engaging in physical activity is a positive behavior and is not considered high-risk. Regular physical activity is important for maintaining overall health and preventing obesity, cardiovascular disease, and other health issues.

B) I use sunscreen with an SPF of 10: While using sunscreen is a protective behavior, an SPF of 10 is lower than the recommended SPF of at least 30 for effective protection against harmful UV radiation. This is not the most significant high-risk behavior compared to others, but it still indicates some risk of sun damage.

C) I limit playing video games to 3 hours per day: Limiting screen time to 3 hours per day can be considered a balanced approach to video gaming. While excessive screen time can be problematic, 3 hours per day is not necessarily a high-risk behavior for an adolescent, as long as it doesn't interfere with other important aspects of life, like physical activity, sleep, and socialization.

D) I have had sexual relations, but did not get the HPV vaccine: Engaging in sexual activity without receiving the HPV vaccine is a high-risk behavior. The HPV vaccine helps prevent certain strains of the human papillomavirus, which can cause cervical cancer and other cancers. Lack of vaccination increases the risk of contracting HPV and developing related complications.

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Correct Answer is D

Explanation

A) Document the infiltration: While documentation is an important part of the nursing process, it is not the first action to take. If an infiltration is suspected, the priority is to stop the infusion immediately to prevent further harm or fluid leakage into the surrounding tissues. Once the infusion is stopped, the nurse can then document the infiltration for medical record purposes.

B) Elevate the arm: Elevating the arm can help reduce swelling, but this should not be the first step. The first priority when infiltration is suspected is to stop the infusion, as continuing it can worsen the tissue damage and swelling. After stopping the infusion, elevating the arm may be considered as part of the subsequent management of the infiltration.

C) Apply a warm compress: A warm compress may be helpful after stopping the infusion, particularly if the infiltration involves non-vesicant fluids. However, applying a warm compress is not the immediate action. The first step should be stopping the infusion to prevent any further fluid from infiltrating the tissues.

D) Stop the infusion: The most immediate and appropriate action when infiltration is noted around the IV insertion site is to stop the infusion. This prevents additional fluid from leaking into the surrounding tissues, which could cause further damage. Once the infusion is stopped, the nurse can take other steps to manage the infiltration, such as assessing the site, applying a warm compress, or notifying the healthcare provider.

A. Offer the client several choices at mealtimes B. Remind the client of the day and time often C. Avoid discussing the client's fears D. Alternate daily caregivers.

Correct Answer is B

Explanation

A) Too many choices can be overwhelming and lead to increased frustration or "decision fatigue" for a confused client.

B) Delirium is characterized by an acute, fluctuating change in mental status. Reorientation helps anchor the client to reality and can reduce the anxiety or agitation associated with cognitive clouding.

C) Ignoring a client's fears can increase their sense of isolation and paranoia. Acknowledging feelings while gently correcting misconceptions is more therapeutic.

D) Consistency is key. Frequent changes in staff increase confusion; it is better to have the same nursing team to build familiarity.

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A nurse is assisting with the care of an adolescent. Which of the following statements should the nurse identify as high-risk behaviors?

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