Assessment data for a 9-year-old reveals that she blurts out answers to questions before the question is completed, is unable to wait her turn, and persistently interrupts and intrudes in the conversations of others. The nurse would assess these behaviors as relating primarily to:
Hyperreflexia.
Defiance.
Inattention.
Impulsivity.
The Correct Answer is D
Choice A Reason
Hyperreflexia refers to an overactive or overresponsive reflexes, which is a neurological condition and not directly related to the behaviors described. It is typically seen in conditions affecting the central nervous system and is not characterized by the inability to wait turns or interrupting conversations.
Choice B Reason
Defiance implies a conscious choice to resist authority or rules, which may not necessarily be the case here. While children with behavioral issues may exhibit defiant behaviors, the symptoms described are more indicative of a lack of impulse control rather than a deliberate choice to defy.
Choice C Reason
Inattention is a component of several behavioral and cognitive disorders, including ADHD. However, the behaviors described—blurting out answers, inability to wait for turns, and interrupting others—are more specifically associated with impulsivity rather than inattention alone.
Choice D Reason
Impulsivity is the tendency to act on a whim, displaying behavior characterized by little or no forethought, reflection, or consideration of the consequences. The behaviors described—such as blurting out answers and interrupting others—are classic signs of impulsivity, which is often seen in conditions like ADHD.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason
While some medications for hypertension can cause visual side effects, it is not the most immediate concern when a patient reports blurred vision. Medication-related side effects are important to consider, but they typically present consistently rather than intermittently.
Choice B Reason
An ophthalmic examination is crucial for evaluating intermittent blurred vision in a client with hypertension. Hypertension can lead to hypertensive retinopathy, where high blood pressure causes damage to the blood vessels in the retina, potentially resulting in blurred vision or vision loss. An eye exam can help diagnose this condition and prevent further complications.
Choice C Reason
Blurred vision can indeed be associated with hypertension, particularly in severe cases or hypertensive crises. However, it is not considered a 'common' problem but rather a sign of potential end-organ damage, such as hypertensive retinopathy, which requires prompt medical evaluation.
Choice D Reason
The risk of brain tumors is not directly associated with hypertension. While hypertension is a risk factor for certain conditions like stroke, it is not typically linked with an increased risk of brain tumors. This choice might cause unnecessary alarm without a clinical basis.
Correct Answer is D
Explanation
Choice A Reason
A creatinine level of 0.8 mg/dL falls within the normal range for adults, which is typically 0.6 to 1.2 mg/dL for males and 0.5 to 1.1 mg/dL for females. This indicates normal kidney function and is not a cause for immediate intervention post-operatively.
Choice B Reason
A potassium level of 4.2 mEq/L is within the normal range, which is generally between 3.6 and 5.2 mEq/L. This level indicates a stable electrolyte balance and is not a cause for immediate concern following shoulder replacement surgery.
Choice C Reason
A white blood cell (WBC) count of 9,000 mm³ is within the normal range, which typically spans from 4,500 to 11,000 WBCs per mm³. This suggests there is no active infection or inflammation that requires immediate intervention.
Choice D Reason
A hemoglobin level of 7.1 g/dL is considered low, as the normal range for adult males is generally 13.8 to 17.2 g/dL and for adult females is 12.1 to 15.1 g/dL. Low hemoglobin can indicate anemia, which may be due to blood loss during surgery or other underlying conditions. This requires immediate intervention to address potential oxygenation issues and determine the cause of the anemia.
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