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 C

Explanation

A) Dampened clothes are used for dusting the area: Using dampened clothes for dusting can help minimize the spread of dust and particulate matter in the environment. As long as the cloth is clean and properly disinfected, this action is not typically a source of infection. This is generally a safer approach for cleaning and does not pose an immediate infection risk.

B) Waste containers are lined with: While the phrasing is incomplete, if waste containers are lined properly with appropriate liners and are disposed of regularly, they should not serve as a significant source of infection. Waste disposal is important, but a properly lined container reduces the risk of contamination.

C) Soiled linens are placed on the floor: Placing soiled linens on the floor is a significant source of potential infection for immunocompromised clients. Floors can harbor bacteria, viruses, and other pathogens, and placing soiled linens there increases the likelihood of cross-contamination. The linens should be handled in a way that prevents contact with unclean surfaces to avoid spreading infection.

D) Uncapped sharps are put in a puncture-resistant container: A puncture-resistant container is designed to safely contain sharps such as needles, scalpels, or other sharp objects, minimizing the risk of injury. If sharps are uncapped, however, they could present a risk of needle-stick injury or contamination. However, the main risk comes from improper disposal, not the container itself. Proper disposal in an appropriately designed container is essential to minimizing infection risks.

A. Document the infiltration B. Elevate the arm C. Apply a warm compress. D. Stop the infusion.

Correct Answer is D

Explanation

A) Document the infiltration: While documentation is an important part of the nursing process, it is not the first action to take. If an infiltration is suspected, the priority is to stop the infusion immediately to prevent further harm or fluid leakage into the surrounding tissues. Once the infusion is stopped, the nurse can then document the infiltration for medical record purposes.

B) Elevate the arm: Elevating the arm can help reduce swelling, but this should not be the first step. The first priority when infiltration is suspected is to stop the infusion, as continuing it can worsen the tissue damage and swelling. After stopping the infusion, elevating the arm may be considered as part of the subsequent management of the infiltration.

C) Apply a warm compress: A warm compress may be helpful after stopping the infusion, particularly if the infiltration involves non-vesicant fluids. However, applying a warm compress is not the immediate action. The first step should be stopping the infusion to prevent any further fluid from infiltrating the tissues.

D) Stop the infusion: The most immediate and appropriate action when infiltration is noted around the IV insertion site is to stop the infusion. This prevents additional fluid from leaking into the surrounding tissues, which could cause further damage. Once the infusion is stopped, the nurse can take other steps to manage the infiltration, such as assessing the site, applying a warm compress, or notifying the healthcare provider.

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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 providing care to a client who is immunocompromised. Which of the following should the nurse identify as possible source of infection?

Correct Answer is C

Explanation

A nurse is caring for client who is receiving a continuous IV infusion . The nurse notes the skin around the catheter's insertion site is edematous and cool. Which of the following actions is should the nurse take First?

Correct Answer is D

Explanation

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