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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Free Nursing Study Resources

Correct Answer is A

Explanation

A) "I should decrease my salt intake to 2 grams per day.":
This statement is correct. For clients with hypertension, a reduced salt intake is essential in managing blood pressure. The general recommendation is to limit sodium intake to less than 2,300 milligrams per day (about 2.3 grams), with an ideal target of 1,500 milligrams per day for individuals with hypertension or those at risk. Reducing salt intake helps lower blood pressure and prevent further complications.

B) "I can have two glasses of wine with dinner.":
This statement is incorrect. While moderate alcohol consumption may not be prohibited, it is important for individuals with hypertension to limit alcohol intake. The American Heart Association recommends no more than one drink per day for women. Two glasses of wine may exceed this limit, which could contribute to an increase in blood pressure.

C) "I should exercise for 5 minutes two times per week.":
This statement is incorrect. Exercise is an important component of managing hypertension, but 5 minutes of exercise twice a week is not sufficient. The general recommendation is for adults to engage in at least 150 minutes of moderate-intensity aerobic exercise or 75 minutes of vigorous-intensity exercise per week, spread throughout the week. More frequent and longer exercise sessions are necessary to improve cardiovascular health and manage blood pressure.

D) "I will set my blood pressure goal at 130 over 84.":
This statement is incorrect. The goal for blood pressure in individuals with mild hypertension is generally lower than 130/80 mm Hg, according to current guidelines. A blood pressure of 130/84 is still considered elevated. The target should be to maintain a blood pressure below 130/80 mm Hg to reduce the risk of cardiovascular complications.

A. Use a moisturizing soap to clean the skin around the client's stoma. B. Create an opening on the skin barrier that is 1.27 cm (0.5 in) larger than the client's stoma. C. Empty the client's ostomy pouch before removing the skin barrier. D. Change the client's ostomy appliance hr after breakfast.

Correct Answer is C

Explanation

A) Use a moisturizing soap to clean the skin around the client's stoma:
Using a moisturizing soap is not recommended for cleaning the skin around the stoma. Moisturizing soaps can leave a residue that may interfere with the adhesion of the ostomy appliance. The skin around the stoma should be cleaned with warm water and mild soap that does not contain lotions, fragrances, or oils. This helps ensure the skin is clean and dry, promoting better adhesion of the skin barrier.

B) Create an opening on the skin barrier that is 1.27 cm (0.5 in) larger than the client's stoma:
The opening in the skin barrier should be about 1/8 inch (approximately 0.32 cm) larger than the stoma's diameter, not 1.27 cm (0.5 in) larger. A larger opening can cause the skin barrier to fit too loosely, leading to leakage and skin irritation. The skin barrier should fit snugly around the stoma to prevent any leakage and protect the surrounding skin.

C) Empty the client's ostomy pouch before removing the skin barrier:
It is essential to empty the ostomy pouch before removing the skin barrier to prevent fecal material from spilling or leaking during the appliance change. This helps maintain cleanliness, reduces the risk of skin irritation, and makes the procedure more comfortable for both the client and the nurse.

D) Change the client's ostomy appliance 1 hour after breakfast:
There is no specific time required after breakfast to change the ostomy appliance. The timing of appliance changes should be based on the client's individual needs and lifestyle, and it is more important to change the appliance when necessary (e.g., when the pouch is full or when the skin barrier is no longer intact) rather than adhering to a specific time after meals.

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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

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Correct Answer is C

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