An adolescent with a congenital heart defect is admitted for diagnostic testing with surgery scheduled in 3 days. Which intervention should the nurse implement to best support the client's psychosocial needs?
Enable limited time for cell phone use.
Provide an activity room to spend time with other adolescents.
Deliver 3 meals and snacks each day upon request.
Allow family and friends to be present during assessments.
The Correct Answer is B
Choice A reason: Enabling limited time for cell phone use is not the best intervention that the nurse can implement to support the client's psychosocial needs. While cell phone use can help the client stay connected with their peers and social media, it can also be a source of distraction and stress. The nurse should encourage the client to balance their cell phone use with other activities that promote their well-being.
Choice B reason: Providing an activity room to spend time with other adolescents is the best intervention that the nurse can implement to support the client's psychosocial needs. This intervention can help the client cope with the anxiety and isolation that may result from their condition and hospitalization. It can also provide an opportunity for the client to interact with other adolescents who have similar experiences and challenges, and to engage in fun and meaningful activities that enhance their self-esteem and mood.
Choice C reason: Delivering 3 meals and snacks each day upon request is not the best intervention that the nurse can implement to support the client's psychosocial needs. While it is important to maintain the client's nutrition and hydration, it is not enough to address their emotional and social needs. The nurse should also encourage the client to eat with other adolescents or family members when possible, and to express their preferences and concerns about their food.
Choice D reason: Allowing family and friends to be present during assessments is not the best intervention that the nurse can implement to support the client's psychosocial needs. While it is important to involve the client's family and friends in their care, it is not necessary to have them present during every assessment. The nurse should respect the client's privacy and autonomy, and ask for their consent before allowing others to observe or participate in their assessments. The nurse should also provide the client with opportunities to talk to their family and friends in a comfortable and confidential setting.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Rice is a gluten-free grain that is safe for people with celiac disease. Rice does not contain the protein gluten that triggers an immune reaction and damages the small intestine in people with celiac disease.
Choice B reason: Oats are generally not recommended for people with celiac disease because they are often contaminated with gluten from other grains during processing. Some people with celiac disease may also react to a protein in oats called avenin that is similar to gluten. Only certified gluten-free oats may be safe for some people with celiac disease, but they should consult their health care provider before consuming them³.
Choice C reason: Barley is a grain that contains gluten and is not safe for people with celiac disease. Barley can cause inflammation and damage to the small intestine in people with celiac disease. Barley is also used to make malt, which is a common additive in many processed foods and beverages.
Choice D reason: Rye is a grain that contains gluten and is not safe for people with celiac disease. Rye can cause the same symptoms and complications as wheat and barley in people with celiac disease. Rye is often used to make bread, crackers, and cereals.
Correct Answer is B
Explanation
Choice A reason: Assessing for presence of a supernumerary breast nipple is not a relevant technique to determine if the client has reached the age of menarche. A supernumerary breast nipple is an extra nipple that develops along the embryonic milk line, usually in the chest or abdomen. It is a congenital anomaly that affects about 1% to 5% of the population, and it has no relation to the onset of menstruation.
Choice B reason: Using the Tanner staging to determine sexual maturity is a valid technique to determine if the client has reached the age of menarche. The Tanner staging is a scale that assesses the development of secondary sexual characteristics, such as breast growth, pubic hair growth, and genital development, in relation to the chronological age of the child. The Tanner staging can help estimate the stage of puberty and the likelihood of menarche, which usually occurs around Tanner stage 3 or 4 in girls.
Choice C reason: Palpating for evidence of temporary gynecomastia is not an appropriate technique to determine if the client has reached the age of menarche. Gynecomastia is the enlargement of breast tissue in males, due to hormonal imbalance, medication side effects, or other causes. It is a common condition that affects up to 70% of adolescent boys, and it usually resolves spontaneously within a few months or years. Gynecomastia has no relevance to the onset of menstruation in girls.
Choice D reason: Calculating approximate age menstruation should occur is not a reliable technique to determine if the client has reached the age of menarche. The age of menarche varies widely among individuals, depending on genetic, environmental, nutritional, and psychosocial factors. The average age of menarche in the United States is about 12.5 years, but it can range from 8 to 16 years. Therefore, calculating the approximate age of menarche based on averages or norms may not reflect the actual situation of the client.
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