A nurse is reinforcing teaching with an adolescent who has ADHD and a new prescription for methylphenidate. Which of the following actions by the adolescent should the nurse identify as a potential barrier is communication?

The adolescent interrupts the nurse to ask question

The adolescent occasionally turns away from the nurse and stares at the wall

The adolescent taps on the arm of the chair throughout the conversation

The adolescent rocks in their chair while speaking with the nurse.

Answer and Explanation

The Correct Answer is C

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.

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Correct Answer is D

Explanation

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.

A. Staff members used a class A fire extinguisher during an electrical fire B. Staff members review the locations of fire extinguishers every 2 to 3 years. C. An evacuation was ordered during a fire when fire extinguishers were not effective. D. Fire alarms in the facility have the same sound as other alarms.

Correct Answer is A

Explanation

A) Staff members used a class A fire extinguisher during an electrical fire.
This response indicates that the safety plan is effective because it shows that the staff used the correct type of fire extinguisher for the fire they encountered. Class A fire extinguishers are designed for ordinary combustibles (e.g., wood, paper, cloth), but using a fire extinguisher that is correctly suited to the fire type demonstrates that the staff are trained and prepared to respond appropriately in an emergency. For electrical fires, however, a Class C fire extinguisher should be used. This suggests a review of fire safety plan training might be necessary to align fire extinguisher types with fire classes.

B) Staff members review the locations of fire extinguishers every 2 to 3 years.
Reviewing the locations of fire extinguishers every 2 to 3 years is not an adequate frequency. Fire safety protocols should be reviewed more frequently to ensure that staff are consistently aware of fire extinguisher locations. Routine and more frequent checks (e.g., annually) are required to ensure proper preparedness in an emergency.

C) An evacuation was ordered during a fire when fire extinguishers were not effective.
While evacuations are necessary in certain situations, an evacuation being ordered because fire extinguishers were ineffective could indicate that the safety plan was not properly executed or that there was an issue with fire extinguisher maintenance or staff training. The effectiveness of fire safety plans should reduce the need for evacuations due to inadequate response efforts.

D) Fire alarms in the facility have the same sound as other alarms.
Fire alarms should have a distinct sound that differentiates them from other types of alarms (e.g., medical or security alarms). If fire alarms have the same sound as other alarms, it could create confusion in an emergency, undermining the effectiveness of the safety plan. The alarm system should be unique and easily identifiable.

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A nurse is reinforcing teaching with an adolescent who has ADHD and a new prescription for methylphenidate. Which of the following actions by the adolescent should the nurse identify as a potential barrier is communication?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the care of a client following electroconvulsive therapy for the treatment of a depressive disorder. Which of the following findings should the nurse expect 15 min following the procedure?

Correct Answer is D

Explanation

A nurse is assisting with the evaluation of a facility's safety plan. Which of the following indicates that the safety plan is effective?

Correct Answer is A

Explanation

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