A school nurse is talking with a 13-year-old female at her annual health-screening visit. Which of the following comments made by the adolescent should be the nurse's priority to address?

I haven't gotten my period yet, and all my friends have theirs."

There's a big pimple on my face, and I worry that everyone will notice it

"None of the kids at this school like me, and I don't like them either."

"My parents treat me like a baby sometimes."

Answer and Explanation

The Correct Answer is C

A) "I haven't gotten my period yet, and all my friends have theirs."

While the concern about not having gotten her period yet is a valid one, it's a common experience during adolescence. Variability in the timing of puberty is normal, and addressing this concern might involve providing reassurance and education about the natural range of development.

B) "There's a big pimple on my face, and I worry that everyone will notice it."

While concerns about physical appearance are common during adolescence, they are less urgent in terms of emotional and psychological well-being. Addressing body image issues is important, but the statement about lack of social acceptance and reciprocal liking indicates potentially deeper emotional challenges.

C) "None of the kids at this school like me, and I don't like them either."

Explanation:

Adolescence is a time of significant emotional and social development. The statement about not being liked by other students and not liking them in return indicates potential social isolation and difficulties in forming positive relationships. Adolescents often seek social acceptance and peer relationships are crucial for their well-being and development.

D) "My parents treat me like a baby sometimes."

This statement suggests a common parent-adolescent dynamic where there might be conflicts about independence and autonomy. While these feelings are valid, they don't necessarily reflect a higher priority concern related to social isolation and peer relationships.

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Correct Answer is C

Explanation

A. "You are being unreasonable, and I will not call your doctor at this hour."

This response is confrontational and dismissive of the client's request. It does not promote a therapeutic interaction and might escalate the situation.

B. "Go back to your room, and I'll try to get in touch with your doctor."

This response might temporarily calm the client, but it’s misleading if the nurse does not intend to call the doctor. It also avoids addressing the client's immediate emotional needs and could result in a loss of trust if the nurse doesn’t follow through.

C. "You must be very upset about something."

This is the most therapeutic response. It acknowledges the client’s feelings without judgment and opens up communication. It allows the nurse to explore the client’s concerns, which is essential in providing appropriate care and support in a psychiatric setting.

D. "I can't call a doctor in the middle of the night unless it's an emergency."

While this statement is factually correct, it can come across as dismissive and could escalate the client's agitation. It does not acknowledge the client's emotions and might make the client feel that their concerns are not being taken seriously.

A. Ask the client to create her own schedule of daily activities. B. Teach the client to use passive communication when interacting with others. C. Determine the client's need for assistance with grooming. D. Limit the client's involvement in unit activities.

Correct Answer is C

Explanation

A. Asking the client to create their own schedule of daily activities may overwhelm them and exacerbate feelings of hopelessness or indecisiveness commonly experienced with depression. The nurse should provide structure and guidance in establishing a manageable routine.

The other options do not align with best practices for caring for a client with major depressive disorder:

B. Teaching passive communication is not appropriate, as assertive communication is typically encouraged to help the client express her needs and feelings effectively.

C.Asking the client to create their own schedule of daily activities may overwhelm them and exacerbate feelings of hopelessness or indecisiveness commonly experienced with depression. The nurse should provide structure and guidance in establishing a manageable routine

D. Limiting involvement in unit activities could further isolate the client and exacerbate her symptoms. Encouraging participation and engagement is generally more beneficial.

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A school nurse is talking with a 13-year-old female at her annual health-screening visit. Which of the following comments made by the adolescent should be the nurse's priority to address?

Nursing Test Bank

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