A nurse is caring for an adolescent client who is scheduled for surgery. Which of the following actions should the nurse take to prepare the child based on their developmental stage?
Discuss how the procedure might affect the client's appearance.
Avoid involving the client in decisions regarding treatment.
Emphasize that the procedure is not a punishment.
Keep equipment out of the client's sight.
The Correct Answer is A
Choice A rationale:
Adolescents are at a stage of development where body image and appearance are of significant importance. Discussing how the procedure might affect the client's appearance allows the nurse to address the adolescent's concerns and fears related to changes in their body. This can help alleviate anxiety and promote a sense of control over the situation, fostering a more positive psychological response to the surgery.
Choice B rationale:
Avoiding involving the client in decisions regarding treatment (Choice B) would not be appropriate for an adolescent. Adolescents are at a stage where they are developing autonomy and decision-making skills. Excluding them from decisions about their treatment could lead to feelings of powerlessness and hinder their sense of control.
Choice C rationale:
Emphasizing that the procedure is not a punishment (Choice C) might be suitable for younger children who might associate medical procedures with punishment. However, adolescents typically do not perceive medical procedures as punishments, so this explanation may not address their specific concerns.
Choice D rationale:
Keeping equipment out of the client's sight (Choice D) might be more relevant for younger children who might be frightened by medical equipment. Adolescents are generally better able to comprehend and cope with the presence of medical equipment. Open communication about the procedure and addressing their concerns directly would be more beneficial.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Iron 100 mcg/dL The normal range for serum iron levels can vary based on age and gender, but typically, a range of 50 to 150 mcg/dL is considered normal. The provided value of 100 mcg/dL falls within this range and is not a cause for concern. Elevated iron levels can be indicative of hemochromatosis or other disorders, but this value is not concerning.
Choice B rationale:
Hemoglobin 8 g/dL Hemoglobin levels can vary by age and gender, but in general, a hemoglobin level of 8 g/dL is low and suggestive of anemia, a condition characterized by a reduced ability of the blood to carry oxygen. Anemia can lead to fatigue, weakness, and other symptoms, and the nurse should report this finding to the healthcare provider for further evaluation and management.
Choice C rationale:
Sodium 140 mEq/L The normal range for serum sodium levels is typically around 135 to 145 mEq/L. The provided value of 140 mEq/L falls within this normal range and is not a cause for concern. Deviations from this range can indicate various conditions, including dehydration or overhydration, but this value is within an acceptable range.
Choice D rationale:
Calcium 9 mg/dL The normal range for serum calcium levels can vary, but generally, a range of 8.5 to 10.5 mg/dL is considered normal. The provided value of 9 mg/dL falls within this range and is not significantly abnormal. Abnormal calcium levels can be indicative of various conditions, including thyroid disorders or kidney problems, but this value is not concerning.
Correct Answer is A
Explanation
Choice A rationale:
The nurse should report the finding of a 6-month-old infant with a spiral fracture to a lower extremity to local authorities. Spiral fractures in infants, especially those who are not yet independently mobile, raise concerns about possible child abuse or non-accidental trauma. The unique pattern of spiral fractures is often associated with twisting forces, which are unlikely to occur accidentally in infants who cannot perform such movements. Reporting such cases is essential to ensure the safety and well-being of the child.
Choice B rationale:
A 9-month-old infant exposed to bedbugs and cellulitis is not an emergency that requires reporting to local authorities. While cellulitis can be serious, it is not an immediate threat to the child's safety, and the focus should be on providing appropriate medical care.
Choice C rationale:
A 4-year-old preschooler with rivalry among siblings does not indicate a need for reporting to local authorities. Sibling rivalry is a common occurrence in families and does not pose a threat to the child's safety. It is a social and developmental issue that can be addressed within the family.
Choice D rationale:
A 24-month-old toddler experiencing occasional incontinence does not require reporting to local authorities. Occasional incontinence can be a normal part of toddler development as they learn to control their bladder. It does not indicate abuse or immediate danger to the child.
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