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 B

Explanation

A) Orange juice:
Orange juice is high in potassium, with one cup containing a significant amount of the nutrient. For clients who need to limit their potassium intake due to an electrolyte imbalance (such as in kidney disease or hyperkalemia), orange juice should be avoided or consumed in limited amounts.

B) Baked chicken breast:
Baked chicken breast is the lowest in potassium among the options provided. While chicken does contain some potassium, it is relatively low compared to fruits and vegetables. This makes it a better choice for clients needing to limit their potassium intake. Lean meats like chicken are often recommended for clients on a restricted potassium diet.

C) Sweet potato:
Sweet potatoes are very high in potassium, especially when compared to many other vegetables. A serving of sweet potato can contain a large amount of potassium, making it unsuitable for clients who need to manage their potassium levels.

D) Cantaloupe:
Cantaloupe is also high in potassium. A single serving can provide a substantial amount of potassium, which can be problematic for clients with electrolyte imbalances who need to limit their potassium intake.

A. Drain the tub water before the client gets out B. Check on the client every 10 min during the bath. C. Add bath oil to the water after the client gets into the tub D. Allow the client to remain in the bath for 30 min.

Correct Answer is A

Explanation

A) Drain the tub water before the client gets out: Draining the water before the client gets out of the tub is the safest option. This helps prevent the risk of slipping or falling, as the water level will lower once the client begins to stand. Additionally, it ensures that the client can safely exit the tub without the danger of being unbalanced or disoriented by the water.

B) Check on the client every 10 min during the bath: While monitoring the client during the bath is important, checking every 10 minutes may not be frequent enough to ensure their safety, especially for clients who have mobility or cognitive issues. Ideally, the nurse should stay with or observe the client more closely or provide assistance if needed. Continuous supervision is preferred, particularly if the client is at risk for falls or other complications.

C) Add bath oil to the water after the client gets into the tub: Bath oils can create a slippery surface, which could increase the risk of falls or accidents. It's generally better to avoid adding oils to the bath water, as they can make the tub and the client’s skin slick, posing safety hazards. If oil is necessary for skin care, it should be applied to the skin after the bath, not in the water.

D) Allow the client to remain in the bath for 30 min: While the client may enjoy a bath, staying in the tub for too long can lead to skin irritation, dehydration, or overheating, especially for older adults or clients with medical conditions. The client should not stay in the water for prolonged periods. A typical recommendation would be to allow the bath to last about 10-20 minutes, depending on the client’s condition and safety.

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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?

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Correct Answer is A

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