A nurse is assisting with the care of a client who has pneumonia.

For each potential nursing action, click to specify if the potential action is anticipated or contraindicated for the client.

A) "The adolescent interrupts the nurse to ask a question": Interrupting is common in adolescents with ADHD, as impulsivity is a characteristic of the disorder. While this behavior can be disruptive, it does not necessarily present a barrier to communication. The adolescent may be seeking clarification, and the nurse can guide them to ask questions at appropriate times.

B) "The adolescent occasionally turns away from the nurse and stares at the wall": This behavior may indicate that the adolescent is distracted or disengaged, but it does not necessarily block communication. It's important for the nurse to assess the adolescent’s attention and attempt to re-engage them if needed.

C) "The adolescent taps on the arm of the chair throughout the conversation": Tapping or other repetitive movements are often seen in individuals with ADHD and can be a significant barrier to effective communication. This behavior can be distracting for both the adolescent and the nurse, making it difficult to maintain focus on the conversation and absorb information. The nurse should address this by encouraging a calmer, more focused posture during discussions.

D) "The adolescent rocks in their chair while speaking with the nurse": Rocking can be a self-soothing behavior or a way to help manage restlessness, common in ADHD. While it can be distracting, it is less likely to be a major barrier to communication than tapping, which may be more intrusive. The nurse should assess if the behavior affects the adolescent’s ability to focus or engage.

A) Tonic-clonic seizures: Tonic-clonic seizures are typically the result of a seizure disorder, but during electroconvulsive therapy (ECT), a controlled seizure is intentionally induced to facilitate the therapeutic effects. After the procedure, there should not be uncontrolled tonic-clonic seizures. The goal is to induce a seizure under controlled conditions during the procedure itself, so this is not an expected finding 15 minutes post-ECT.

B) Paresthesias: Paresthesias (tingling or numbness) are not a common immediate side effect following ECT. While ECT can have some neurological effects, paresthesias are more commonly associated with other neurological conditions or nerve injuries, rather than as a direct result of the procedure itself.

C) Sleep apnea: Sleep apnea is not a typical immediate consequence of ECT. While ECT can have a range of physical and psychological side effects, sleep apnea, which involves breathing interruptions during sleep, is not an expected finding following the procedure.

D) Disorientation: Disorientation is a common and expected finding following ECT. It typically occurs due to the temporary effects of anesthesia, the brain’s response to the electrical stimulation, and the stress of the procedure. Clients often experience confusion, memory loss, and disorientation for a short period, particularly in the first 15 minutes after the procedure, as the anesthesia wears off and they recover from the induced seizure. This is a normal part of the recovery process.