A nurse is caring for an adolescent who requests screening for sexually transmitted infections (STI). The client asks the nurse. "Do you have to tell my parents?" How should the nurse respond to the adolescent?

"We only have to tell your parents if your test comes back positive."

"We need your parents" permission if you are on their insurance."

"We will have to get your parents' consent before testing you for STIs."

“We can test you for STIs without informing your parents."

Answer and Explanation

The Correct Answer is D

Rationale:

A. "We only have to tell your parents if your test comes back positive.": Giving conditional privacy based on test results is misleading. Confidentiality in STI testing applies regardless of the outcome and is protected by law in many regions for adolescents.

B. "We need your parents' permission if you are on their insurance.": Insurance coverage does not determine the legal right to consent. While explanation of benefits forms may create confidentiality challenges, consent laws usually allow minors to access STI testing independently.

C. "We will have to get your parents' consent before testing you for STIs.": Requiring parental consent for STI testing contradicts legal protections in many areas that allow minors to access sexual and reproductive health care without parental involvement.

D. “We can test you for STIs without informing your parents.": Supporting the adolescent's autonomy and legal rights, this answer provides accurate information about confidential care and encourages open, respectful communication between the nurse and client.

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Correct Answer is B

Explanation

Rationale:

A. The client needs strict measurement of intake and output: This task can be delegated to assistive personnel as it involves routine data collection without complex clinical judgment.

B. The client develops a postoperative fever: A postoperative fever may indicate infection or other complications requiring assessment, clinical judgment, and intervention by a registered nurse.

C. The client is experiencing a therapeutic effect from their treatment: Monitoring expected therapeutic effects is routine and can often be overseen by licensed practical nurses or assistive personnel, depending on policy.

D. The client needs routine wound care performed: Routine wound care is generally a delegated nursing task that does not require the advanced assessment or clinical decision-making of an RN unless complications arise.

A. Mix the medication in juice prior to administration B. Administer the medication when the toddler has an acute asthma attack C. Provide an additional dose of the medication prior to physical activity. D. Administer the medication to the toddler each evening

Correct Answer is D

Explanation

Rationale:

A. Mix the medication in juice prior to administration: Montelukast can be mixed with soft foods like applesauce, but mixing it in juice is not specifically recommended due to potential taste masking and dosing accuracy issues. Instructions should follow the manufacturer’s guidelines.

B. Administer the medication when the toddler has an acute asthma attack: Montelukast is a maintenance medication used to prevent asthma symptoms and is not effective for treating acute asthma attacks. A rescue inhaler like albuterol should be used during acute episodes.

C. Provide an additional dose of the medication prior to physical activity: Montelukast is not typically dosed in response to physical activity. While it can help prevent exercise-induced bronchospasm, it should be taken once daily in the evening, not additionally before exertion.

D. Administer the medication to the toddler each evening: Montelukast is prescribed as a once-daily maintenance therapy and is most effective when given in the evening. This helps maintain consistent blood levels and prevents nighttime asthma symptoms.

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A nurse is caring for an adolescent who requests screening for sexually transmitted infections (STI). The client asks the nurse. "Do you have to tell my parents?" How should the nurse respond to the adolescent?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is giving a report to their supervisor. Which of the following indicates a need for client care to be transferred to a registered nurse?

Correct Answer is B

Explanation

A nurse is reinforcing teaching with the parents of a toddler who has a new diagnosis of asthma and a prescription for montelukast. Which of the following instructions should the nurse include in the teaching?

Correct Answer is D

Explanation

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