A nurse is talking with a 13-year-old female client who is having her annual health-screening visit. Which of the following comments by the client should concern the nurse?
"My parents treat me like a baby sometimes."
"There's a pimple on my face, and I worry that everyone will notice it."
"I start taking ibuprofen a few days before my period starts."
"None of the kids at my school like me, and I don't like them either."
The Correct Answer is D
A. "My parents treat me like a baby sometimes." This statement reflects a common adolescent feeling of striving for independence and experiencing frustration when treated as a child. It is a normal part of adolescent development and not a cause for immediate concern.
B. "There's a pimple on my face, and I worry that everyone will notice it." Concern about appearance is typical for adolescents due to the increased focus on body image and peer perception. This statement is a normal expression of adolescent self-consciousness.
C. ``I start taking ibuprofen a few days before my period starts." Using ibuprofen preemptively for menstrual cramps is a reasonable self-care practice for adolescents experiencing menstrual discomfort. This statement does not indicate any immediate health concern.
D. "None of the kids at my school like me, and I don't like them either." This statement indicates social isolation and potential issues with peer relationships, which can be a red flag for emotional distress or depression. It may suggest that the adolescent is experiencing significant difficulties in their social life that could lead to more serious mental health concerns.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Restrain the toddler for 1 hr after the procedure: This is not necessary; the child should be monitored but not restrained.
B. Place the toddler in a side-lying, knee-chest position: This position helps to open the spaces between vertebrae, facilitating the lumbar puncture.
C. Ask another nurse to assist with holding the toddler in a prone position: The prone position is not appropriate for a lumbar puncture as it does not provide proper spinal alignment.
D. Swaddle the toddler in a warm blanket: While comforting, it is not relevant to the procedure itself.
Correct Answer is D
Explanation
A. Low-pitched cry: A high-pitched cry, not a low-pitched one, is more typical of increased ICP in infants. A low-pitched cry is not a common sign of ICP and may be more related to other conditions.
B. Positive Babinski reflex: The Babinski reflex is normal in infants up to about 1 year of age and is not indicative of increased ICP. It is a normal finding and not specific to increased intracranial pressure.
C. Insomnia: Infants with increased ICP may exhibit irritability and changes in sleeping patterns, but insomnia (difficulty sleeping) is not a classic symptom. The focus should be on other more specific signs like changes in cry and physical appearance.
D. Bulging fontanel: A bulging fontanel is a key sign of increased ICP in infants. It occurs due to pressure within the skull causing the soft spot on the head to protrude. This is a classic symptom of increased intracranial pressure in infants.
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