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Difficulty: HardSupport Systems

A nurse is assessing a 15-year-old client who is 26 weeks pregnant and recently moved into a foster home. The client states, "I don't need anyone's help. I am going to drop out of high school, get my own apartment, and raise this baby completely by myself." Which response by the nurse is the most appropriate to assess the client's support system?

  1. A
    Before we discuss your living arrangements, we need to review the warning signs of preterm labor.
  2. B
    You are not legally or financially ready to live alone; you need to let your foster parents take care of you.
  3. It sounds like you want to be very independent. Who are the people in your life right now that you feel safe relying on?Answer
  4. D
    Why do you feel that dropping out of high school is the best option for your baby's future?

Answer

The most appropriate response acknowledges the client's desire for independence while utilizing an open-ended question to gently probe the reality of her current support network.
The correct response validates the adolescent's developmental need for autonomy and independence while simultaneously using an open-ended question to assess the reality of her current support network. This therapeutic approach builds trust and encourages the client to reflect on who she can realistically rely on without feeling judged or interrogated.

Step-by-Step Solution

1
Analyze the client's statement and current clinical picture.
The client is a pregnant adolescent in a new foster home expressing an unrealistic plan to live completely independently, indicating a severe lack of reliable support systems and a potential threat to her safety.
Identifying the underlying psychosocial vulnerability is the required first step in the nursing process before selecting an intervention.
2
Apply developmental principles to the client's behavior.
According to Erikson's stages of psychosocial development, the client is in the 'Identity vs. Role Confusion' stage. Her desire to 'do it completely by myself' is a normal developmental drive for autonomy, even though it is manifesting in an unsafe plan.
Nursing interventions must be developmentally appropriate; dismissing an adolescent's drive for independence will cause them to withdraw and reject care.
3
Evaluate the nursing responses to find the one that assesses support without blocking communication.
The response that validates her desire to be independent and follows up with an open-ended question about safe people in her life is selected.
This therapeutic approach builds trust and encourages the client to reflect on her support network without feeling judged or controlled.

Key Concept

Therapeutic Assessment of Support Systems in Adolescents
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Topics

Support Systems

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