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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) Ensuring that creases in the stockings on the front of the client's legs:
This action requires intervention. The stockings should be applied smoothly and without any wrinkles or creases, as these can cause pressure points that may lead to skin irritation, impaired circulation, or discomfort for the client. The nurse should ensure that the assistive personnel applies the stockings correctly and without any creases to prevent these issues.
B) Applying the stockings before the client gets out of bed:
This is an appropriate action. Antiembolic stockings should be applied while the client is in a resting position, preferably before getting out of bed, to prevent venous stasis and improve circulation. Applying them while the client is lying down allows for proper fitting and ensures the stockings are worn during periods of immobility.
C) Asking the client to point their toes before applying the stockings:
This is an acceptable action. Asking the client to point their toes helps to stretch and align the legs for proper stocking application, making it easier to apply the stockings without causing discomfort. It is a good practice to ensure the stockings are applied properly while the client's feet and legs are positioned correctly.
D) Turning the stockings inside out before applying them:
This is a correct action. Turning the stockings inside out can help to prevent the stockings from rolling or bunching during application. It also allows the assistive personnel to place them on the client more easily and ensures a proper fit. The stockings should be turned right-side out after being applied to the legs.
Correct Answer is B
Explanation
A) "Tape the tube to the child's cheek."
Taping the tube to the child's cheek is not appropriate for securing a gastrostomy enteral tube. The tube should be securely anchored to the child's abdomen to prevent dislodgment or irritation. Taping to the cheek can lead to unnecessary friction or skin breakdown.
B) "Secure the tubing to the child's abdomen."
The proper method to secure a gastrostomy tube is to anchor the tubing to the child’s abdomen with a specialized securing device or adhesive bandage. This ensures the tube remains in place, minimizing movement and preventing irritation or accidental removal. Proper securing also promotes comfort and safety for the child.
C) "Apply water-soluble lubricant to the site."
Water-soluble lubricant should not be applied directly to the gastrostomy site. This can cause irritation or create a barrier that inhibits proper healing. Instead, the site should be kept clean and dry, with appropriate care to prevent infection or breakdown.
D) "Attach an extension tube to the site's opening prior to use."
While attaching an extension tube may be necessary for feeding or drainage, this action is not related to site care. The focus of site care is to ensure the gastrostomy tube remains securely in place, and the skin around the site is maintained without infection or irritation. Extension tubes are used for feeding or medication administration, not for routine site care.
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