A nurse is preparing to administer methylphenidate 25 mg PO to a school-age child who has ADHD. Available is methylphenidate 10 mg/5 mL liquid. How many ml should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero)

Rationale for correct choice:

• Determine the client's level of anxiety to check for the risk of self-harm: Assessing the client’s anxiety is vital in identifying any risk of self-harm or suicidal thoughts, especially after trauma. This helps the nurse provide appropriate interventions to ensure the client's safety.

Rationale for incorrect choices:

• Tell the client their consent is not required prior to collecting potential physical evidence: The nurse must obtain the client’s consent before collecting any physical evidence. Consent is a legal and ethical requirement, especially in cases of sexual assault.
• Ask the client if they often walk alone when out in public places: This question may inadvertently lead to feelings of guilt or self-blame and is not an immediate priority. The focus should be on addressing the trauma and the client's current needs.
• Avoid asking the client open-ended questions during the interview: Open-ended questions allow the client to express their feelings and experiences, which is essential in trauma care. Avoiding them could hinder the client’s ability to share and may limit the nurse’s understanding of the situation.

Rationale for correct choices:

• Seizures: Seizures are a severe and life-threatening manifestation of alcohol withdrawal that require immediate intervention. They may lead to complications like injury or status epilepticus if not managed promptly.
• Increased blood pressure: Elevated blood pressure is a common sign of alcohol withdrawal and increases the risk of cardiovascular events such as stroke. Close monitoring and intervention are necessary to prevent complications.
• Increased heart rate: Tachycardia is commonly seen in alcohol withdrawal, increasing the risk of arrhythmias and cardiovascular stress. Management of heart rate is essential for maintaining stability.
• Diaphoresis: Diaphoresis, or excessive sweating, is part of the autonomic response during alcohol withdrawal and indicates significant distress in the body. It requires monitoring to ensure proper fluid and electrolyte balance.
• Vomiting: Vomiting in alcohol withdrawal can lead to dehydration and electrolyte imbalances, which can worsen the client’s condition. Immediate attention and interventions are needed to prevent further complications.
• Tremulousness: While often mild, tremors indicate CNS hyperexcitability and can escalate to more severe forms of withdrawal, including seizures or delirium tremens. It requires close monitoring and often pharmacological management to prevent progression.

Rationale for incorrect choices:

• Impaired cognition: Impaired cognition may occur due to alcohol intoxication or withdrawal but does not require immediate medical attention unless it is severe enough to affect the client’s ability to function or respond appropriately.
• Insomnia: Insomnia is common in alcohol withdrawal and can be distressing, but it is not life-threatening. It can be managed through appropriate therapeutic interventions but does not require urgent care.
• Lack of appetite: Loss of appetite is a common symptom of alcohol withdrawal and may be associated with gastrointestinal symptoms. It should be monitored but does not require immediate follow-up unless it leads to severe malnutrition.
• Malaise: Malaise is a general symptom of alcohol withdrawal and indicates a general sense of discomfort. It is important to monitor but does not require immediate intervention unless accompanied by more severe symptoms.