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Flashcards in Chapter 17 Deck (12):
1

What is the most important goal when caring for an individual with anorexia nervosa?
a. Encourage weight gain
b. Correct malnutrition
c. Limit fluid intake
d. Provide effective oral care

Ans: B
Correct malnutrition is the priority goal of treatment.
The individual with anorexia nervosa would probably not be receptive to encouragement of weight gain because of the complex etiology of the disorder. Anorexics often have low self-esteem and have a need for control, which they meet by controlling their eating.
Fluids are often restricted by the individual with anorexia. It is important to correct fluid and electrolyte imbalances if present and not restrict fluid intake.
Oral and dental care is more of an issue with the bulimia nervosa patient secondary to the excessive purging or vomiting episodes.

2

What is characteristic of children with posttraumatic stress disorder (PTSD)?
a. Denial as a defense mechanism is unusual.
b. Traumatic effects cannot remain indefinitely.
c. Previous coping strategies and defense mechanisms are not useful.
d. Children often play out the situation over and over again in an attempt to come to terms with their fear.

Ans: D
This is an expected response by a child to a traumatic event. Play is often the safest means of communication for children and should be encouraged as a means of expression with a child experiencing PTSD.
Denial is a defense mechanism commonly used by children and adolescents.
Professional help is indicated if the stages of response are prolonged.
Coping strategies and defense mechanisms that have been effective previously may be effective for PTSD.

3

When caring for the suicidal adolescent, the most important nursing intervention is
a. emphasizing that a suicide attempt is an immature way of dealing with stress
b. paying particular attention to children who are withdrawn and are giving away their personal belongings
c. ignoring threats of suicide because they are usually bids for attention
d. recognizing a suicide attempt as an impulsive act resulting from a temporary crisis

Ans: B
It is imperative that the nurse recognize warning signs of a potential suicide.
For the depressed youngster, suicide may appear to be the only way out, and telling a child that he or she is immature in feelings or behavior will exacerbate an already crisis-laden situation.
All threats of suicide must be taken seriously and should never be ignored.
Even if the crisis is temporary, the child's perception may be that suicide is the only way out of it.

4

The most appropriate question to ask a rape victim prior to the start of the physical examination is
a. Has she showered or bathed since the attack?
b. Does she think rape is a violent crime?
c. How many items did the attacker take?
d. When the attack occurred, could she have prevented it?

Ans: A
The nurse needs to document if the patient has bathed or showered prior to collecting evidence from the rape. Cleaning the body could remove trace body secretions, such as saliva, semen, or blood, left by the perpetrator, which would be important to collect if possible.
It is not appropriate to ask the patient if she thinks rape is a violent crime.
It is not a priority to ask how many items the attacker took from her.
It is not appropriate to ask the patient if she could have prevented the attack.

5

The nurse is collecting history on a 16-year-old admitted for treatment of anorexia nervosa. The patient limits the answers to yes or no. What is the primary nursing goal for this patient at this time?
a. Ask about favorite foods to provide for them to eat.
b. Return to ask further questions when the patient wants to talk.
c. Discuss the treatment plan and expected stay in the hospital.
d. Develop a positive rapport with the patient.

Ans: D
The nurse would focus on development and establishing a positive rapport with the patient at the early stage. Eating disorders in children often stem from low self-esteem. Children with eating disorders may have low self-esteem and a lack of trust in others. It is important to establish a trusting relationship with the patient.
Asking the patient about favorite foods is not a question that will build rapport with the patient.
Returning to ask further questions when the patient wants to talk is not the primary nursing goal at this time.
Discussing the treatment plan and expected stay in the hospital is not an appropriate goal because the patient is not open to discussion at this time.

6

A nurse is assessing a patient diagnosed with attention deficit hyperactive disorder (ADHD). What behavior would the nurse anticipate the patient to demonstrate?
a. Ability to complete school work during class
b. Requires reminders to keep focused and on task
c. Is defiant with parents and refuses to complete chores at home
d. Is aggressive with peers when asked to participate in team sports

Ans: B
Children with ADHD are often not able to remain focused and require frequent reminders to remain focused and complete an assigned task. They generally are not able to complete work at school and require extra time to complete assignments.
The ability to complete school work during class is not something the nurse would anticipate this patient to demonstrate.
Defiance with parents and refusal to complete chores at home are not behaviors the nurse would anticipate this patient to demonstrate.
Aggression with peers when asked to participate in team sports is not typical of ADHD behavior.

7

The nurse is discussing health behaviors with a 14-year old who recently began smoking cigarettes. An appropriate tactic for the nurse to use when discussing this lifestyle choice is
a. cigarette smoking is only “cool” in high school and is not accepted in college.
b. cigarette smoking can cause permanent damage to the lungs and can cause cancer as an adult.
c. cigarettes are expensive, and a 14-year-old will not be able to afford them, so he should stop smoking.
d. cigarettes contain nicotine, and this will cause addiction to other drugs.

Ans: B
Cigarette smoking can cause permanent damage to the lungs and can cause cancer as an adult. At 14, the child only thinks of the present. The nurse would need to include and explain, and even use pictures to illustrate, what might happen to the body if the child continues to smoke.
Saying cigarette smoking is only cool in high school and is not accepted in college is not a useful tactic the nurse should use when discussing smoking cigarettes.
Suggesting that cigarettes are not affordable and the 14-year-old should therefore stop smoking is not a healthy approach to teaching adolescents to stop smoking.
Cigarettes contain nicotine, and this will cause addiction to other drugs. Adolescents are not often concerned with whether cigarette smoking will lead to other addictions.

8

The nurse is teaching a class on the dangers of “huffing.” What information is included as a major side effect of “huffing?”
a. Cardiac arrest
b. Loss of vision
c. Delay of growth
d. Loss of consciousness

Ans: D
Skin discoloration is not a side effect of huffing.
Cardiac arrest is not typically a major side effect of huffing.
Loss of consciousness and respiratory arrest are major side effects of huffing.
Delay of growth is not a side effect of huffing.

9

A nurse working with adolescents is aware of common drugs of abuse. Which of the following drugs is the most common drug of abuse in the adolescent population?
a. Alcohol
b. Morphine
c. Cocaine
d. Oxycontin

Ans: A
Alcohol is the drug most often used and abused by the adolescent population. The ease of access and the low cost make alcohol the drug of choice for many teenagers.
Morphine is not the most common drug of abuse in the adolescent population.
Cocaine is not the most common drug of abuse in the adolescent population.
Oxycontin is not the most common drug of abuse in the adolescent population.

10

A nurse is working with teenagers and their parents in a school drug prevention program. Several of the parents ask how they can determine if their child has a problem with drugs. The most appropriate response by the nurse is
a. “There is no way to know until they tell you.”
b. “At some point, the child will develop depression and attempt suicide; then you can put them in rehab.”
c. “It is common for them to withdraw and not achieve normal developmental tasks. You should then consult a professional.”
d. “You should make your child take a home test for drugs. You can buy those at the drug store.”

Ans: C
Children and teenagers who begin using drugs may often stop participating in routine activities and not continue to achieve the normal milestones of the adolescent period. If the parent ever has a question, they should seek information from a health care provider.
Waiting for the child to tell the parent is not a way to determine if the child has a problem with drugs. It is a very passive approach to parenting.
Waiting for the child to develop depression and attempt suicide is not a preventive approach to handling drug use.
Taking a home test for drugs is not a measure that should be taken unless the child has been caught engaging in drug use.

11

A 15-year-old female is in a free clinic seeking information on birth control. The girl tells the nurse that she is sexually active with multiple partners. She states that she does not want to have to remember to take a pill every day. The most appropriate birth control option for this patient is
a. an intrauterine device.
b. abstinence.
c. diaphragm.
d. condom.

Ans: D
Condom use is recommended for birth control in teens who are sexually active with multiple partners.
An intrauterine device is not a method of birth control that protects from sexually transmitted diseases.
Abstinence is not an effective approach to birth control for a teen who is sexually active with multiple partners.
A diaphragm is not a method of birth control that protects from sexually transmitted diseases.

12

Which symptoms are commonly seen in a child with depression? (Select all that apply.)
a. Focus on violence
b. Excessive laughing
c. Somatic complaints
d. Increased motor activity
e. Poor school performance

Ans: C, E