Chapter 13: Developmental Management of Adolescents and Young Adults

Garzon Maaks: Burns’ Pediatric Primary Care, 7th Edition

MULTIPLE CHOICE

1. The primary care pediatric nurse practitioner is performing a well child assessment on a 13-
year-old female whose mother asks when her daughter’s periods may start. Which information
will the nurse practitioner use to help estimate the onset of periods?
a. The age of the mother’s menarche
b. The patient’s age at thelarche
c. When adrenarche occurred
d. Whether linear growth has stopped
ANS: B
Thelarche, or the development of breast budding, generally precedes menarche by 2.5 years,
so this should be determined when attempting to predict this milestone. The age of the mother
at menarche is not a reliable indicator. Adrenarche is related to adrenal and not gonadal
development and is less valid than other secondary sex characteristics in assessing sexual
maturation. Rapid linear growth usually begins after thelarche and peaks about a year later but
is not used to predict menarche.

2. The primary care pediatric nurse practitioner is examining a 15-year-old female who reports
having her first period at age 13. She states that she has had five periods in the last year, with
the last one 2 months prior. She participates in basketball at school. Which action is correct?
a. Perform biometric screening to determine lean body mass.
b. Prescribe oral contraceptives pills to regulate her periods.
c. Reassure her that this is perfectly normal at her age.
d. Refer her to an endocrinologist for hormonal evaluation.
ANS: A
Although it can take 18 to 24 months for adolescents to establish regulatory cycles, periods
can also be affected by athletic activity that decreases body fat. The PNP should assess the
percentage of lean body mass, which should be 75% or less to maintain regular ovulatory
cycles. OCPs are useful for regulating periods if this persists and other causes are ruled out. It
is not necessary to refer her to an endocrinologist unless problems persist in spite of standard
management.

3. During a well child assessment of a 13-year-old male, the primary care pediatric nurse
practitioner notes small testicles and pubic and axillary hair. To further evaluate these
findings, the nurse practitioner will ask the patient about what topic?
a. alcohol and tobacco use
b. changes in voice
c. increase in height and weight
d. participation in sports
ANS: D
 The initial sign of puberty in males is testicular enlargement. If this does not precede other
changes, the PNP should consider whether the boy is taking exogenous anabolic steroids,
common among those who wish to improve athletic ability. These findings are not concerning
for alcohol or tobacco use. Voice changes and rapid growth may occur with pubic hair
development, but the primary concern is anabolic steroid use.

4. The mother of a 16-year-old male was recently divorced after several years of an abusive
relationship and tells the primary care pediatric nurse practitioner that the adolescent has
begun skipping school and hanging out with friends at the local shopping mall. When she
confronts her child, he responds by saying that he hates her. What will the nurse practitioner
tell this mother?
a. Adolescence is marked by an inability to comprehend complex situations.
b. Adolescence is typically marked by tempestuous and transient episodes.
c. Adolescents normally have extreme, disruptive conflicts with parents.
d. Adolescents often need counseling to help them cope with life events.
ANS: D
Adolescent brains respond differently to toxic stress, so counseling is indicated to help them
manage serious events, such as family abuse and divorce. Early adolescents have concrete
thinking, but the formal operational thinking occurs later. “Storm and stress” are not the norm
in adolescence nor are disruptive periods of conflict.

5. The primary care pediatric nurse practitioner is performing a well child exam on a 12-year-old
female who has achieved early sexual maturation. The mother reports that she spends more
time with her older sister’s friends instead of her own classmates. What will the nurse
practitioner tell this parent?
a. Early-maturing girls need to identify with older adolescents to feel a sense of
belonging.
b. Girls who join an older group of peers may become sexually active at an earlier
age.
c. Spending time with older adolescents indicates a healthy adjustment to her
maturing body.
d. The association with older adolescents will help her daughter to gain social
maturity.
ANS: B
While it is true that early maturing females may join an older group of peers to feel that they
fit in, the ones who do put themselves at risk for risky behaviors, including sexual activity.
Although many teens feel awkward when they mature at different rates than their peers,
joining a group of older peers demonstrates a poor adjustment and does not promote social
maturity.

6. The primary care pediatric nurse practitioner is performing an exam on an adolescent male
who asks about sexual identity because of concern that a friend is worried about being gay.
Which response will the nurse practitioner make in this situation?
a. Provide the teen with a questionnaire to gain information about his sexuality.
b. Remind the adolescent that mandatory reporting requires disclosure to parents.
c. Suggest that the adolescent discuss sexual concerns with his parents.
d. Tell the adolescent that, unless he is at risk, what he says will be confidential.
ANS: D
 Adolescents should be encouraged to divulge information about their sexuality to providers by
assuring them that confidentiality will be maintained unless the health of the child or others is
at risk. The adolescent may be trying to ask questions about himself in a manner that doesn’t
implicate his own sexuality, so the PNP should attempt to gain his confidence. Questionnaires
may be useful when collecting information, but this adolescent has already begun a discussion
about the topic. An adolescent who is concerned about being gay may not be ready to come
out to his parents.

7. The parent of a 14-year-old child tells the primary care pediatric nurse practitioner that the
child skips classes frequently in spite of various disciplinary measures, such as grounding and
extra homework and is earning Cs and Ds in most classes. What will the nurse practitioner
recommend?
a. Counseling for emotional problems
b. Development of an Individual Education Plan
c. Evaluation for possible learning disorders
d. Referral for a behavioral disorder
ANS: C
Frequent school absenteeism, class skipping, and other types of school avoidance may
indicate a problem with cognitive ability and should be assessed. When cognitive disorders
are ruled out, other issues, such as behavioral and emotional problems may be considered.
IEPs are used for children who have identified special physiological or cognitive needs and
may be useful if a cognitive disorder is identified.

8. The parent of a 14-year-old child tells the primary care pediatric nurse practitioner that the
adolescent has expressed a desire to be a vegetarian, is refusing all meat served at home, and
wants the family to eat vegetarian meals. What will the nurse practitioner tell the parent?
a. Do not allow a vegetarian diet in order to maintain appropriate limits for the
adolescent.
b. Provide vegetarian options for the adolescent that preserve adequate nutrition and
protein intake.
c. Suggest that the adolescent prepare appropriate vegetarian dishes to complement
family meals.
d. Tell the adolescent that a vegetarian diet may be considered in adulthood but not
while living at home.
ANS: C
Early adolescents begin to develop their own value system and may try value systems other
than the one that they have learned from their family, which is a normal part of establishing
personal identity. The parent may allow expression of other values, such as a vegetarian diet,
as long as nutritional needs are met and the adolescent takes responsibility for preparing the
food.

9. The primary care pediatric nurse practitioner is performing a well child exam on a 17-year-old
female whose mother is present during the history. The mother expresses concern that her
daughter wishes to have an eyebrow piercing and states that she is opposed to the idea. What
will the nurse practitioner do?
a. Provide information about piercings and encourage continued discussion.
b. Remind the adolescent that her mother is responsible for her health.
c. State that piercings are relatively harmless and are an expression of individuality.
 d. Suggest that she wait until she is 18 years old and can make her own decisions.
ANS: A
Adolescents who pierce their noses or have strange haircuts may be irritating to parents, but
these are ways of expressing individuality and help them to achieve psychosocial milestones.
The fact that the teen and her mother are discussing this is a good sign that the adolescent isn’t
in complete rebellion. The PNP should provide accurate health information and encourage
continued dialogue. Although it is true that piercings are relatively harmless, the PNP
shouldn’t “side” with the teen during an open discussion or tell the teen that the mother is “in
charge.”

10. The parent of an adolescent reports noting cutting marks on the teen’s arms and asks the
primary care pediatric nurse practitioner what it means. What will the nurse practitioner tell
this parent?
a. Cutting is a way of dealing with emotional distress.
b. It is a method of fitting in with other adolescents.
c. The behavior is common and will usually stop.
d. This type of behavior is a type of suicide attempt.
ANS: A
Self-injurious behavior (SIB) is used as a coping strategy to relieve distress, anger, and stress.
It is not commonly done among adolescents and is not a way of fitting in with a peer group.
Because it indicates underlying distress, adolescents must get help identifying these causes.
Many have a history of physical, sexual, or emotional abuse. Although individuals who
engage in SIB are more likely to attempt suicide in the future, the act itself is not a suicide
attempt.