Pre-Test 1 and 2: Introduction to Special Questions Based on Official NCLEX-RN[®]
66. A teenager with sickle cell anemia tells a clinic nurse that the school has arranged for a nature hike in the nearby mountains. The teen excitedly shows the nurse a new water bottle that has been purchased just for this trip. Which initial response by the nurse would be most appropriate?
. "You realize that this kind of hike might send you into a pain crisis, don't you?"
. "You should not attend the hike unless you get approval from the physician first."
. "It's great that you are preparing to hydrate properly on your hike. How else have you planned for the hike?"
. "That sounds like a lot of fun and is terrific exercise. What do your parents think?"
Test-Taking Tip
Be wary of selecting answers that sound condescending or judgmental. Remember that a teenager with a chronic health condition should have a reasonable sense of possible activity limitations while also having a developmental need to be like peers. The best strategy for the nurse is to explore with the teen the challenges of participating in a mountain hike and to work together to meet mutual health goals.
Content Area: Child Health, Hematological; Integrated Process: Nursing Process, Implementation; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/Reduction of Risk Potential/Potential for Alterations in Body Systems
Pre-Test 1 and 2: Introduction to Special Questions Based on Official NCLEX-RN[®]
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Answer 1 is incorrect because it sounds as though the nurse assumes the child has not thought about the potential hazards of the hike. This statement may block effective communication between the nurse and the teenager. Answer 2 is incorrect because the statement implies that the nurse is withholding approval until after a physician's review. This statement prevents effective exchange of communication between the nurse and the teenager. Answer 3 is correct because the nurse first provides praise for a positive health behavior, then opens up the conversation into a discussion about additional steps that should be taken to promote the child's health. Answer 4 is incorrect because, although the nurse may want to know how the parents feel about the hike, it is better for the nurse to first explore the teenager's plans and attitudes. If the nurse specifically asks about the parents' thoughts, the teen may feel that the nurse is seeking to block participation in the activity.