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. Capillary refill less than 2 seconds: A capillary refill time of less than 2 seconds indicates good peripheral circulation, which is normal and not a cause for concern in this context. It is not the priority.
B. Tingling in the right foot Rationale: Tingling (paraesthesia) can be a sign of nerve damage or compromised circulation, which may indicate complications such as compartment syndrome. This is a priority finding because it can lead to severe consequences if not addressed promptly.
C. 2+ right pedal pulse Rationale: A 2+ pedal pulse indicates a normal pulse strength, which suggests that there is adequate blood flow to the extremity. It is not a priority compared to the potential for neurological or circulatory compromise.
D. Respiratory rate 24/min Rationale: A respiratory rate of 24/min is within the normal range for a school-age child (18-30 breaths per minute). While it is important to monitor vital signs, it is not a priority concern related to the fracture.
Correct Answer is C
Explanation
A. Temporal: The temporal artery is not commonly used for pulse checks in infants as it can be difficult to palpate and may not provide an accurate heart rate.
B. Carotid: The carotid pulse is not recommended in infants due to the risk of compressing the airway or carotid artery, leading to decreased blood flow to the brain.
C. Apical: The apical pulse is the most reliable method for assessing heart rate in infants. It involves auscultating the heart directly at the chest, which provides the most accurate heart rate measurement.
D. Dorsalis pedis: This site is not typically used for pulse checks in infants as it can be difficult to locate and palpate accurately.
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