A nurse is caring for an adolescent.
Admission Assessment
1400:

• Adolescent brought to emergency department by parents following a fall while skateboarding.
• Adolescent reports pain in their right leg as 10 on a scale of 0 to 10 and is unable to bear weight.
• Adolescent is awake, alert, and oriented x 3. Lungs clear, respirations even and regular. S1 and S2 with regular rate and rhythm.
• Abdomen soft and nontender with active bowel sounds in all four quadrants.
• Right lower extremity with open wound and displaced bone.
• Right lower extremity pulse +1, extremity cool to touch, edema present, capillary refill 4 seconds.

Select the 4 findings that require follow-up.

A is incorrect because the completion of the incident report should not be documented in the client's medical record, but in a separate file for quality improvement purposes.

B is correct because the time the medication was given is an essential fact related to the incident that should be documented in the client's medical record.

C is incorrect because the reason for the medication error should not be documented in the client's medical record, but in the incident report for analysis and prevention of future errors.

D is incorrect because the notification of the pharmacist should not be documented in the client's medical record, but in the incident report for follow-up and corrective actions.

A. Intellectual impairment

- The correct answer is ID.

- Intellectual impairment is a core feature of ID, which is characterized by significant limitations in intellectual functioning and adaptive behavior that are present before age 18.

- Intellectual impairment can sometimes be a feature of ADHD, but it's not a defining characteristic. ADHD, or Attention Deficit Hyperactivity Disorder, primarily involves difficulties with attention, hyperactivity, and impulsivity. However, some individuals with ADHD may also experience challenges with certain aspects of cognitive function, such as executive function, working memory, and processing speed. These difficulties can sometimes be mistaken for intellectual impairment, but it's important to note that ADHD itself does not necessarily indicate lower intelligence. ADHD is a neurodevelopmental disorder that affects individuals differently, and many people with ADHD have average or above-average intelligence..

B. Losing necessary things

- The correct answer is ADHD.

- Losing necessary things is a common symptom of ADHD, especially in the inattentive subtype. Children with ADHD may have difficulty organizing their belongings, remembering where they put them, or keeping track of them.

- Losing necessary things is not a specific indicator of ID, although children with ID may also have difficulties with memory and organization.

C. Impaired language skills

- The correct answer is ID.

- Impaired language skills are often associated with ID, as language development depends on cognitive abilities and social interactions. Children with ID may have delays or difficulties in acquiring, understanding, or using spoken or written language.

- Impaired language skills are not a typical feature of ADHD, although some children with ADHD may have coexisting language disorders or learning disabilities.

D. Hyperreactivity to sensory input

- The correct answer is ADHD.

- Hyperreactivity to sensory input is a possible manifestation of ADHD, especially in the hyperactive-impulsive subtype. Children with ADHD may be easily distracted by external stimuli, such as noises, lights, or movements, or may seek sensory stimulation by fidgeting, touching, or moving around.

- Hyperreactivity to sensory input is not a characteristic of ID, although some children with ID may also have sensory processing issues or autism spectrum disorder.

E. Interrupting others

- The correct answer is ADHD.

- Interrupting others is another common sign of ADHD, especially in the hyperactive-impulsive subtype. Children with ADHD may have difficulty waiting their turn, following social rules, or respecting others' boundaries. They may blurt out answers, comments, or questions without thinking or listening.

- Interrupting others is not a typical behavior of children with ID, although some children with ID may also have social skill deficits or communication problems.