Level: Foundational
Difficulty: Easy
Subtopic: Adolescent development
NCLEX: A 16-year-old adolescent at a primary care visit is being evaluated for developmental expectations for adolescent…
Psychology / lifespan development Health Promotion and Maintenance
Case Study
A 16-year-old adolescent at a primary care visit is being evaluated for developmental expectations for adolescent development. Assessment data include screening reveals vaping, poor sleep, and declining grades. Which finding requires the nurse to intervene immediately?
Question
A. A stable, long-standing finding that matches the expected care plan.
B. A comfort request with unchanged vital signs and no new symptoms.
C. The new finding that screening reveals vaping, poor sleep, and declining grades.
D. Routine data unchanged from the prior assessment.
B. A comfort request with unchanged vital signs and no new symptoms.
C. The new finding that screening reveals vaping, poor sleep, and declining grades.
D. Routine data unchanged from the prior assessment.
Rationale
Correct answer: C. The new finding that screening reveals vaping, poor sleep, and declining grades.
Rationale: Follow-up items test whether the nurse recognizes cues that are new, acute, or inconsistent with stability and need prompt nursing action.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Follow-up items test whether the nurse recognizes cues that are new, acute, or inconsistent with stability and need prompt nursing action.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.