The nurse is asking a diagnosed schizophrenic patient how they slept and they respond, "This is a new day in May and I can't wait to play." Which communication pattern does the nurse identify?

The correct answer is choice D: "I haven't gotten my period yet, and all my friends have theirs."

Choice D rationale:

This comment should be the nurse's priority to address because it raises concerns about the adolescent's sexual development and reproductive health. A delay in the onset of menstruation might indicate underlying medical issues, and addressing this topic can provide reassurance and information about normal variations in puberty. It also demonstrates the nurse's commitment to addressing the adolescent's physical well-being.

Choice A rationale:

While concerns about physical appearance are valid, in the context of an annual health-screening visit, addressing potential medical issues takes precedence. While the nurse can provide guidance on skincare and self-esteem, these topics can be discussed after addressing the primary health concern.

Choice B rationale:

Social interactions are important for adolescents, but the comment about not being liked by peers does not present an immediate health concern. This issue may be better addressed in a broader discussion about the adolescent's emotions and social well-being.

Choice C rationale:

Feeling treated like a baby by parents is a common sentiment during adolescence. While it is valuable to acknowledge and discuss these feelings, they are not the priority in this context, where the nurse should focus on physical health and development.

Choice A rationale:

Administering medication to sedate the client is not the appropriate initial action. The client's confusion and restlessness could be due to various factors, and administering sedative medication without identifying the cause of these symptoms could lead to adverse effects or mask underlying issues.

Choice B rationale:

Calling the family to stay with the client might provide emotional support, but it doesn't directly address the client's safety needs. The client's increasing confusion and restlessness require a more immediate intervention to ensure their safety.

Choice C rationale:

Applying wrist and leg restraints should be a last resort and is not the appropriate initial action in this situation. Restraints should only be used if less restrictive interventions have failed and the client's safety is at risk. Restraints can lead to complications such as decreased mobility, skin breakdown, and increased agitation.

Choice D rationale:

Correct Choice Moving the client to a room closer to the nurses' station is the most appropriate action in this scenario. This intervention helps to increase the client's visibility and proximity to nursing staff, making it easier to monitor and address their needs promptly. It also promotes a safer environment while allowing the healthcare team to assess the underlying causes of the restlessness and confusion.