A nurse is caring for an adolescent who lives on their own and is refusing treatment. Which of the following statements should the nurse make? You can only refuse treatment for STI testing.

You will need a parent or guardian to make this medical decision for you.

You must be married in order to make your own health care decisions.

You have the right to refuse this treatment.

Answer and Explanation

The Correct Answer is D

Choice A reason:

The nurse should inform the adolescent of their right to refuse treatment because respecting the patient's autonomy and right to make their own decisions about their healthcare is essential. This is especially true for an adolescent who is living on their own, as they have the legal capacity to make their medical decisions independently.

Choice B reason:

This statement is incorrect because, in most jurisdictions, adolescents who live on their own are considered emancipated minors, meaning they have the legal right to make their medical decisions without involving a parent or guardian. Requiring a parent or guardian's consent would not be applicable in this situation.

Choice C reason:

This statement is incorrect and irrelevant to the situation. Marriage status does not determine an individual's ability to make their own health care decisions. Regardless of marital status, an adolescent living on their own has the right to make their medical choices.

Choice D reason:

This is the correct choice. The nurse should emphasize the adolescent's right to refuse treatment if they wish to do so. It is crucial to respect their autonomy and ensure that they are fully informed about the potential consequences of their decision. However, the nurse should also provide relevant information about the treatment's benefits and risks to help the patient make an informed decision.

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Correct Answer is B

Explanation

Choice A reason:

Obtaining vital signs is essential in assessing the child's overall condition, but it is not the first action the nurse should take in this situation. The priority is to address the immediate concern of difficulty breathing.

Choice B reason:

Stopping the IV infusion is the most critical action the nurse should take first. Difficulty breathing can be a sign of a severe allergic reaction, and if it is related to the IV cefuroxime, stopping the infusion will prevent further administration of the medication and possibly worsening the reaction.

Choice C reason:

Administering epinephrine IM is not the first-line action in this scenario. Epinephrine is used in severe anaphylactic reactions, but it should not be given without a proper evaluation of the situation and a clear indication for its use.

Choice D reason:

Monitoring intake and output is an important nursing intervention, but it is not the priority when the child is experiencing difficulty breathing. Addressing the respiratory distress should be the initial focus to ensure the child's safety and well-being.

A. FACES Scale. B. Numerical scale. C. FLACC pain assessment scale. D. Visual analog scale.

Correct Answer is C

Explanation

Choice A reason:

The FACES Scale is a visual pain scale typically used for children who can understand and verbalize their pain intensity. It consists of a series of faces with varying expressions, from smiling to crying, to help the child express their pain level. However, since the client in question is nonverbal and has cognitive and developmental delays, this scale may not be suitable as they might not be able to communicate using this tool effectively.

Choice B reason:

The Numerical Scale involves asking the patient to rate their pain on a scale of 0 to 10, with 0 being no pain and 10 being the worst pain imaginable. While this scale is commonly used for older children and adults, it may not be appropriate for a nonverbal and developmentally delayed 9-year-old client, as they may not understand or be able to use numbers effectively to express their pain.

Choice C reason:

The FLACC pain assessment scale is designed for nonverbal or preverbal individuals, including children and those with cognitive impairments. FLACC stands for Face, Legs, Activity, Cry, and Consolability. Each category is scored from 0 to 2 or 0 to 3, depending on the version used, based on specific observed behaviors. The scores are then totaled to give an overall pain assessment. This scale is particularly suitable for the current client's condition as it focuses on observable behaviors rather than verbal communication.

Choice D reason:

The Visual Analog Scale (VAS) requires the patient to mark a point along a line that represents their pain intensity, with one end indicating no pain and the other end indicating the worst pain. Although this scale is useful for older children and adults, it may not be appropriate for a 9-year-old client with cognitive and developmental delays who might not fully comprehend the concept of the scale.

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A nurse is caring for an adolescent who lives on their own and is refusing treatment. Which of the following statements should the nurse make? You can only refuse treatment for STI testing.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting in the care of a child who is receiving IV cefuroxime when the child begins to have difficulty breathing. Which of the following actions should the nurse take first?

Correct Answer is B

Explanation

A nurse is caring for a 9-year-old client who is immediately postoperative. The client is nonverbal and has both cognitive and developmental delays. Which of the following pain scales should the nurse use to evaluate the client's pain?

Correct Answer is C

Explanation

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