The nurse is assessing a school aged child with ADHD. The child is prescribed dexamethylphenidate 10mg before breakfast and lunch. Which of the following findings is of MOST concern to the nurse?

Sleeping 8 to 10 hours a night

Heart rate 90 beats per minute at rest

Blood pressure reading of 140/90

Weight gain of 2 kgs since last visit

Answer and Explanation

The Correct Answer is C

A. Sleeping 8 to 10 hours a night is within the normal range for a school-aged child.
B. A resting heart rate of 90 beats per minute is within the normal range for a child.
C. A blood pressure reading of 140/90 is concerning as it indicates hypertension, which can be a side effect of stimulant medications like dexamethylphenidate.
D. A weight gain of 2 kgs is not immediately concerning in a growing child, though weight should be monitored.

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Correct Answer is ["B","C","D"]

Explanation

A. Use of consistent caregivers is beneficial for children with Autism Spectrum Disorder as it provides stability and predictability.
B. Overstimulation from the environment (e.g., noise, lights, activity) can lead to anxiety and frustration in children with Autism Spectrum Disorder.
C. Illness and pain are distressing and can increase anxiety and frustration, especially if the child has difficulty communicating their discomfort.
D. Changes in the child's routine can be particularly unsettling and may lead to anxiety and frustration.
E. Providing short, simple instructions helps in clear communication and reduces confusion, which can minimize anxiety.

A. Avoiding further palpation of the abdomen B. Obtaining an accurate height and weight C. Monitoring vital signs D. Assessing the urine for the presence of blood

Correct Answer is A

Explanation

A. Avoiding further palpation of the abdomen is crucial to prevent rupture of the tumor and potential spread of cancer cells.
B. Obtaining an accurate height and weight is important but not as critical as preventing tumor rupture.
C. Monitoring vital signs is essential but not the priority intervention in this context.
D. Assessing the urine for the presence of blood is important for overall assessment but not the most critical intervention compared to avoiding tumor rupture.

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The nurse is assessing a school aged child with ADHD. The child is prescribed dexamethylphenidate 10mg before breakfast and lunch. Which of the following findings is of MOST concern to the nurse?

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