Nokea
A child is diagnosed with attention deficit hyperactivity disorder and is prescribed lisdexamfetamine. The child and his parents return to the clinic for a follow-up visit. The mother reports that his behavior has improved and 'he's been sleeping okay at night.' She also says, 'He seems to eat like a bird sometimes and he's so thin.' The child's weight and height are within the lower percentiles for his age. When developing the plan of care for this child, which nursing diagnosis would the nurse most likely identify as the priority?
- A. Disrupted Sleep Patterns
- B. Ineffective Coping
- C. Imbalanced Nutrition: Less Than Body Requirements
- D. Ineffective Breathing Pattern
Correct Answer: C
Rationale: Based on the assessment findings, the child is clearly having difficulty with nutritional intake. Therefore, Imbalanced Nutrition: Less Than Body Requirements would be the priority. The mother reports that the child's sleeping is 'okay,' so disturbed sleep patterns would not be an issue. There is no evidence to suggest ineffective coping or ineffective breathing pattern.
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A child is prescribed dexmethylphenidate. When developing the teaching plan for the child and parents, the nurse instructs the parents to administer the drug at which time? Select all that apply.
- A. After breakfast
- B. Before breakfast
- C. After lunch
- D. Before lunch
- E. At bedtime
Correct Answer: B,D
Rationale: The nurse should instruct the client's parents to administer dexmethylphenidate 30 to 45 minutes before breakfast and before lunch.
When describing how analeptics increase the depth of respirations, the pursing instructor addresses the stimulation of chemoreceptors. The instructor would identify these chemoreceptors as being located in which area in the body. Select all that apply.
- A. Upper aorta
- B. Left ventricle
- C. Jugular vein
- D. Carotid artery
- E. Pulmonary vein
Correct Answer: A,D
Rationale: Analeptics increase the depth of respirations by stimulating chemoreceptors located in the carotid arteries and upper aorta.
A 10-year-old child is receiving a CNS stimulant as treatment for ADHD. When developing the teaching plan for the parents, the nurse would include instructions about recording which of the following periodically?
- A. Social interaction
- B. Weight and growth
- C. Voiding pattern
- D. Sleeping pattern
Correct Answer: B
Rationale: The nurse should instruct the parents to monitor the weight and growth patterns of the child. The child's social interaction or sleeping pattern need not be recorded unless specified by the primary health care provider. Since the drugs administered for ADHD do not cause urinary retention, there is no need to monitor urinary patterns.
A client has been prescribed an amphetamine as part of obesity treatment. Which of the following would the nurse document before initiating the prescribed regimen?
- A. Temperature
- B. Weight
- C. Blood glucose level
- D. Arterial blood gas results
Correct Answer: B
Rationale: Before administering amphetamine as part of obesity treatment, the nurse should record the client's weight. There is no need to record the client's temperature or blood glucose level. Arterial blood gas results are reviewed when a CNS stimulant is prescribed for respiratory depression but not for obesity treatment.
A nurse is reviewing the medical record of a client. Which of the following conditions, if found, would the nurse identify as a condition in which CNS stimulants should be avoided? Select all that apply.
- A. Severe hypotension
- B. Hyperthyroidism
- C. Diabetes
- D. Cardiac disease
- E. Seasonal allergies
Correct Answer: B,D
Rationale: CNS stimulants should not be given to clients with cardiac disease, severe hypertension, or hyperthyroidism. Diabetes and seasonal allergies are not contraindications for use of CNS stimulants.