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1. What is the most important information the registered nurse (RN) should obtain about Joe's accidents? A) Explanation of previous accidents. Feedback: CORRECT Asking the client to elaborate on his comment by describing his accidents will help the RN better understand the nature and circumstances regarding his previous mishaps. B) Injuries that resulted from the accidents. Feedback: INCORRECT Although this information might be of value, it will probably not elicit the information most needed by the nurse. C) Precipitating events to the accidents. Feedback: INCORRECT Although this information might be of value, it will probably not elicit the information most needed by the nurse. D) What Joe means by the word "accident." Feedback: INCORRECT Although this information might be of value, it will probably not elicit the information most needed by the nurse. Joe goes on to say that he fractured his clavicle when he "wasn't paying attention to where he was going" and fell in a hole. The next time, he was running down the stairs and broke his foot. This time, he was trying to lift a roll of fencing wire by himself and let the roll slip and sustained a wrist laceration. The nurse learns that Joe was diagnosed with attention deficit hyperactivity disorder (ADHD) a few months ago. Points Earned: 0.0/1.0 Correct Answer(s): A 2. What is a hallmark characteristic of ADHD? A) Family history of ADHD. Feedback: INCORRECT Although ADHD has a genetic component, it is not a characteristic that defines ADHD. B) High number of accidents. Feedback: INCORRECT Although multiple accidents are symptomatic of this behavioral disorder, this is not a hallmark characteristic of ADHD. C) Pattern of impulsiveness. Feedback: CORRECT Impulsivity, inattentiveness, and hyperactivity are all hallmark characteristics of ADHD. D) Difficulty maintaining peer relationships. Feedback: INCORRECT Difficulties with peer relationships are symptomatic of many behavioral disorders including ADHD. Points Earned: 1.0/1.0 Correct Answer(s): C 3. The nurse recognizes which statement by Joe supports his diagnosis of ADHD? A) "I was known as the school rebel in high school." Feedback: INCORRECT This statement may suggest Oppositional Defiant Disorder (ODD). ODD is often comorbid with ADHD, but it is not diagnostic of ADHD. B) "I do all right in my classes if they are interesting." Feedback: INCORRECT Individuals with ADHD often excel in subjects they find interesting, but academic performance is not a diagnostic criteria for ADHD. C) "I complete all my assignments and turn them in." Feedback: INCORRECT Individuals with ADHD usually fail to finish tasks. D) "I get bored easily." Feedback: CORRECT Individuals with ADHD frequently complain of being bored. Points Earned: 1.0/1.0 Correct Answer(s): D The client is treated for his laceration. As the nurse is giving discharge instructions, the young man makes the statement, "I know I am clumsy; I wish there were a pill for that." 4. How should the nurse respond to Joe's statement? A) Tell Joe to see his healthcare provider (HCP). Feedback: INCORRECT Recommending that clients see their HCP without explanation has the potential for increasing their level of anxiety. B) Recommend an accident prevention class. Feedback: INCORRECT Identification of the reason for the client's accident-prone behavior, be it ADHD or not, takes priority over prevention issues. C) Suggest journaling the facts of the accidents. Feedback: INCORRECT Although journaling the facts surrounding the client's accidents might be helpful, individuals with ADHD often become bored with such tasks. D) Acknowledge the client's frustration. Feedback: CORRECT Acknowledgment of the client's emotional frustration enhances the therapeutic relationship. Points Earned: 1.0/1.0 Correct Answer(s): D The nurse recommends that Joe talk with his primary health care provider regarding his concerns. Joe calls the office and speaks with the nurse. The primary health care provider refers Joe to a mental health provider. Joe arrives at the mental health provider's office with his mother, and the nurse greets them and begins the assessment. The nurse asks the reason for Joe's visit to the clinic. Joe tells the same story to the clinic nurse that he told to the emergency center nurse. 5. The nurse recognizes which statement by Joe supports his previous diagnosis of ADHD? A) "I have had a lot of girlfriends." Feedback: CORRECT Adults and teens with ADHD often have difficulties with relationships. B) "I often leave movies after 30 minutes." Feedback: INCORRECT By late adolescence, individuals with ADHD are likely to have developed skills to compensate for their difficulties in situations that require them to sit quietly and concentrate. C) "I don't like to play games with others." Feedback: INCORRECT Difficulty playing non-physical games, such as board games, is common in young school-age children with ADHD. D) "My mom says I interrupt her." Feedback: INCORRECT Parents of young school-age children with ADHD frequently complain of the child interrupting, but by late adolescence most teens have developed social skills that compensate for this behavior. Points Earned: 0.0/1.0 Correct Answer(s): A 6. Which activity should the nurse recognize as having the highest priority in a safety assessment for Joe? A) History of motor vehicle violations. Feedback: INCORRECT Discussion of previous accidents may give the nurse clues for assisting the client in developing behaviors to prevent future accidents, but this is not the priority. B) Recreational activities. Feedback: INCORRECT Involvement in recreational activities such as hunting, etc., may place the client at increased risk of injury because of the use of weapons and the prevalence of impulsivity in clients with ADHD, but this is not the highest priority. C) Sexual activity. Feedback: INCORRECT Sexual activity patterns are a safety issue, but not the highest priority because of the implications of sexually transmitted diseases. D) Drug and alcohol use. Feedback: CORRECT Recreational drug and alcohol use is the highest priority for two reasons. First, alcohol and drug use increases problems with judgment about risky behavior, and second, they may be a contraindication for stimulant medications. Points Earned: 0.0/1.0 Correct Answer(s): D Planning The nurse prepares a problem list and nursing care plan for Joe's medical record. 7. Which issue should the nurse assign the highest priority in Joe's problem list? A) Low self-esteem. Feedback: INCORRECT Emotional issues are important when treating the individual with ADHD, but addressing the issues that lead to feelings of low self-esteem does not take priority over Joe's physical safety. B) Impaired interpersonal relationships. Feedback: INCORRECT Emotional issues are important when treating the individual with ADHD, but addressing the issues that lead impaired interpersonal relationships does not take priority over Joe's physical safety C) At risk for injury. Feedback: CORRECT Regardless of the situation, safety is always the priority of the nurse's care. The impulsivity associated with ADHD places the client at increased risk of injury. D) Poor academic/occupational performance. Feedback: INCORRECT Individuals with ADHD may benefit from referral for academic/occupational counseling, but the priority is Joe's physical safety. Points Earned: 1.0/1.0 Correct Answer(s): C During Joe's second visit to the clinic, the nurse reviews Joe's nursing care plan. 8. Which nursing intervention should the RN implement to meet Joe's biopsychosocial needs? A) Bibliotherapy. Feedback: INCORRECT Bibliotherapy, or the use of books, is not the best intervention to meet Joe's biopsychosocial needs at this time. B) Support groups. Feedback: INCORRECT Support groups are not the best intervention to meet Joe's biopsychosocial needs at this time. C) Printed handouts. Feedback: CORRECT For individuals with ADHD, interventions that are detail oriented or that require a significant amount of concentration or time investment are less appealing and often less well received than interventions that do not. Because printed handouts are typically definitive and concise, they can be useful resources for individuals with ADHD. D) Internet resources. Feedback: INCORRECT Internet resources are not the best intervention to meet Joe's biopsychosocial needs at this time. Points Earned: 0.0/1.0 Correct Answer(s): C Joe makes the statement "Gee, I thought the only thing we were going to do was start my medicine." 9. How should the nurse respond to Joe's comment? A) "I want to do everything I can to help you." Feedback: INCORRECT Although the statement utilizes the therapeutic communication skill of offering of one's self, it does not explain the reason why other areas of Joe's life must be explored. B) "ADHD affects many aspects of your life." Feedback: INCORRECT This response is somewhat vague. Individuals with ADHD respond better to more concrete statements. C) "Treatment involves more than taking medication." Feedback: CORRECT This statement by the nurse opens the door for a discussion of the psychosocial issues and other treatment options for clients with ADHD. D) "Medication alone won't improve your school work." Feedback: INCORRECT Negative statements such as this can diminish the client's sense of hope. Points Earned: 0.0/1.0 Correct Answer(s): C The HCP prescribes methylphenidate (Concerta 54 mg tablets) to treat Joe’s ADHD. Intervention Again, Joe's mother accompanies him on his follow-up visit. The nurse prepares for Joe's visit after starting methylphenidate (Concerta). 10. What is the most important biological parameter for the nurse to assess after a client has started taking Concerta? A) Weight. Feedback: CORRECT Because weight loss is a common adverse reaction to stimulant medication, it should be regularly assessed. B) Blood Pressure. Feedback: INCORRECT Although stimulants can raise blood pressure, it is less of a concern for a healthy male in late adolescence and does not have the same priority as another biological parameter. C) Height. Feedback: INCORRECT Although there have been some studies suggesting a relationship between stimulants and growth retardation, Joe has most likely reached his adult growth. D) Pulse. Feedback: INCORRECT Although individuals taking stimulant medication may experience benign transient tachycardia, pulse rate does not have the same priority as another biological parameter. Points Earned: 0.0/1.0 Correct Answer(s): A 11. Given Joe's inattentiveness and short attention span, what is the most important strategy for the nurse to use when planning care? A) Verbalization of feelings should be encouraged. Feedback: INCORRECT Clients with ADHD should be encouraged to explore and verbalize the relationship between feelings and behavior, but this is not the priority. B) Interventions should be time-limited. Feedback: CORRECT Because of the client's short attention span, all interventions should be relatively short. C) Nursing interventions should be performed by the same nurse. Feedback: INCORRECT Although interaction with the same nurse strengthens the nurse-client relationship. D) Verbal information should be reinforced with written material. Feedback: INCORRECT This is a good intervention given that individuals with ADHD are often forgetful, but it is not the priority when planning for an ADHD client with a short attention span. Points Earned: 1.0/1.0 Correct Answer(s): B 12. Which nursing diagnosis should the nurse address when planning for Joe's care? A) Impaired social interaction related to poor communication skills. Feedback: CORRECT Communication skills can be independently addressed by the nurse. B) Impaired verbal communication related to inattentive behavior. Feedback: INCORRECT The nurse cannot easily change the client's inattentiveness. C) Potential for injury related to impulsive behavior. Feedback: INCORRECT Impulsivity is an issue that the nurse can address, but her ability to positively impact the client's impulsivity is limited. D) Ineffective roll performance related to school success. Feedback: INCORRECT The client should be referred to appropriate educational counselors to address school performance. Points Earned: 0.0/1.0 Correct Answer(s): A Educational Interventions The nurse is preparing the medication teaching plan prior to giving Joe his Concerta. 13. What is the most important information for the nurse to tell Joe about the stimulant medication he has been prescribed? A) Medication tolerance. Feedback: INCORRECT Although clients treated with stimulants should be reminded that misuse of the medication may lead to drug tolerance and render the drug less effective or useless, it is not the priority. B) Legal issues. Feedback: CORRECT All clients on stimulants should be reminded that the drug is a controlled substance. Adolescents and younger adults may be questioned more rigorously should they be stopped for such things as traffic violations, etc. Young adults and teens must be reminded that criminal charges can be filed if the client is unable to produce information that identifies himself/herself as one who is being treated with stimulants. C) Adverse drug interactions. Feedback: INCORRECT Clients should always be advised of drug interactions, but it is not the priority of the teaching plan. D) Onset of action. Feedback: INCORRECT Although clients should be aware of the onset of action of the medication, it is not the priority of the teaching plan. Points Earned: 0.0/1.0 Correct Answer(s): B Joe asks the nurse what caused him to acquire ADHD. 14. How should the nurse respond to Joe's question? A) Sugar in diet. Feedback: INCORRECT Sugar in the diet is not the cause of ADHD. B) Poor parenting techniques. Feedback: INCORRECT Poor parenting techniques is not the cause of ADHD. C) Watching too much television. Feedback: INCORRECT Watching too much television is not the cause of ADHD. D) Unknown. Feedback: CORRECT The cause of ADHD is unknown, but genetic predisposition is likely. It is thought that medical and environmental factors may also contribute to ADHD. Points Earned: 1.0/1.0 Correct Answer(s): D 15. Joe asks the nurse when he should take his medication. How should the nurse respond? A) At bedtime. Feedback: INCORRECT Taking the medication at bedtime may cause insomnia. B) With each meal. Feedback: INCORRECT Although Concerta may be taken with food or without food, it is not taken at every meal. C) In the morning. Feedback: CORRECT The Concentra 54 mg tablet is an extended release table that is taken once each day in the morning. D) Every 12 hours. Feedback: INCORRECT Although Concerta is an extended release medication, it is not taken every 12 hours. Points Earned: 1.0/1.0 Correct Answer(s): C Joe's mother remarks that it might be difficult for Joe to remember to take medicine. 16. How should the nurse respond to the mother's statement? A) "You are probably worrying needlessly about Joe becoming addicted." Feedback: INCORRECT Although clients taking Concerta are monitored for signs of addiction, this response offers false assurance. B) "Individuals taking Concerta have difficulty getting an euphoric effect." Feedback: INCORRECT Individuals with ADHD who abuse the medication often become lethargic or sluggish. C) "Addiction does not occur when a person with ADHD takes Concerta." Feedback: INCORRECT Stimulants such as Concerta can be addictive and should be taken only as prescribed. D) "The person taking the medication has to be responsible for taking it correctly." Feedback: CORRECT Regardless of what the clinician or parent does, a client Joe's age is ultimately responsible for taking the medication as prescribed. Joe's mother calls the clinician's office because of her concerns regarding Concerta. After ensuring that there is a release of information form on file, the nurse returns the call. Joe's mother tells the nurse that she is afraid Joe will become addicted to the medication. Points Earned: 1.0/1.0 Correct Answer(s): D Joe's mother asks the nurse other questions about medications appropriate for ADHD treatment. She tells the nurse that she understands that there are medications other than stimulants being used to treat ADHD. 17. How should the nurse respond? A) "Stimulants are the gold standard for treating ADHD." Feedback: CORRECT Although several medications are considered to be as efficacious as stimulants, stimulants are the drug of choice for treating ADHD. B) "Come to Joe's next appointment to discuss your concern." Feedback: INCORRECT Since Joe is an adult, he is the only one who can invite his mother to come to his appointment. C) "Joe's history does not suggest that stimulants should be avoided." Feedback: INCORRECT The lack of a history of stimulant use/abuse does not suggest that the client is immune from stimulant dependence. D) "We have talked with Joe about other medications for ADHD." Feedback: INCORRECT Although this statement may offer some assurance to Joe's mother, it does not explain the rationale for using stimulants. Points Earned: 0.0/1.0 Correct Answer(s): A Communication and Social Skills 18. Which problem has priority for the nurse when helping Joe improve his communication skills? A) Assertiveness. Feedback: INCORRECT Assertive communication will be helpful, but it is unlikely to be the primary reason for the client's communication difficulties. B) Intrusiveness. Feedback: CORRECT Intrusiveness or interrupting others is a common trait among individuals with ADHD. Individuals with ADHD often engage in intrusiveness and, along with other behaviors such as, argumentative behavior can lead to conflicts putting the client at risk for physical injury. C) Indifference. Feedback: INCORRECT Indifference may cause the client to miss information important to communication, but this is not the priority. D) Inattentiveness. Feedback: INCORRECT Information regarding how to be an active listener could be helpful, and active listening is more appropriately defined as a therapeutic communication technique, but this is not the priority. Points Earned: 1.0/1.0 Correct Answer(s): B 19. After observing Joe exhibit behaviors that indicate his self-esteem may have suffered as a result of his ADHD, which intervention should the nurse implement to improve his self-esteem? A) Question Joe about the reasons for his relationship difficulties with the opposite sex. Feedback: INCORRECT It is unlikely that Joe will be able to identify specific reasons for his failed relationships. B) Develop a behavior modification plan to change his methods of social interaction. Feedback: INCORRECT In order to modify maladaptive behavior, one must first identify the maladaptive behavior. C) Encourage the client to list three of his positive attributes. Feedback: CORRECT Encouraging the client to identify his/her positive attributes will assist in improving the client's self-esteem. D) Explore with the client areas of his life that he wants to improve. Feedback: INCORRECT The individual with low-self esteem will often be unable to identify specific areas on which they can focus. Points Earned: 0.0/1.0 Correct Answer(s): C Follow-Up Visit Joe presented to the clinic for a follow-up visit after a semester of college. He tells the nurse that he had four "Bs" and an "A." He also says that he is enjoying life at college. 20. The nurse can measure improvement in Joe's social skills by which statement? A) "I have had the same girlfriend for six months now." Feedback: CORRECT At Joe's initial presentation, he remarked that he had difficulty maintaining a relationship with the opposite sex. This statement gives a measurable parameter of time that exhibits an improvement. B) "Meeting new people at parties is enjoyable." Feedback: INCORRECT Although this subjective response suggests improvement, it is not measurable. C) "I find parties and being with other people fun." Feedback: INCORRECT The client's subjective statement about having fun is not an accurate measure of improvement. D) "It is easier for me to focus on what people say to me." Feedback: INCORRECT Without further exploration, this response offers little insight into the client's progress and it is not measurable. Points Earned: 0.0/1.0 Correct Answer(s): A 21. When assessing Joe for improvement in his self-esteem, what is the best approach for the nurse to use? A) "Tell me about the things that have improved this semester." Feedback: CORRECT Because this approach uses a broad opening to gain client information, it will provide the most subjective data. B) "What areas of your life have improved since starting Concerta?" Feedback: INCORRECT Although this question will encourage the client to focus on behavioral changes, it may be difficult for the client to readily identify what they are. C) "Do you feel that your life has changed over the last six months?" Feedback: INCORRECT This question is an example of non-therapeutic communication. D) It sounds like a lot has changed over the last six months. Feedback: INCORRECT This approach is an example of reflective communication. Reflection may not provide the data that the nurse needs to evaluate the client's improvement. Points Earned: 1.0/1.0 Correct Answer(s): A During the course of the conversation, Joe tells the nurse that he has noticed some changes in the effectiveness of his medication. 22. How should the nurse respond to Joe's comment? A) "Have you been feeling better or worse?" Feedback: INCORRECT This is not the best approach because without further exploration, it could result in a one word answer. B) "Tell me what is different now." Feedback: INCORRECT Although this approach may result in the collection of meaningful data, it is not specific to Joe's statement. C) "What changes are of concern to you?" Feedback: CORRECT The nurse asks the client to describe the specific issues that have changed. D) "What has gotten worse over the last few months?" Feedback: INCORRECT This question assumes that Joe has noticed a worsening of his symptoms, which may or may not be the case. Points Earned: 0.0/1.0 Correct Answer(s): C Joe tells the nurse that he sometimes has difficulty falling asleep. 23. What is the first behavior the nurse should ask about when assessing Joe's sleep problem? A) Alcohol consumption. Feedback: INCORRECT Alcohol consumption is not the priority when assessing sleep problems. B) Illegal drug use. Feedback: INCORRECT Illegal drug use is not the priority when assessing sleep problems. C) Caffeine ingestion. Feedback: INCORRECT Caffeine ingestion is not the priority when assessing sleep problems. D) Medication schedule. Feedback: CORRECT Medication dosing schedule is the priority concern when assessing sleep problems. Focusing on negative behaviors such as alcohol consumption, illegal drug use, or caffeine ingestion may place the client on the defensive are not the priority. Points Earned: 0.0/1.0 Correct Answer(s): D 24. What should the nurse assess at Joe's follow up visit? A) Altered nutritional status. Feedback: INCORRECT Although possible, altered nutrition is usually less of an issue for adults with ADHD than it is for children with the disorder. B) Mood/anxiety disorders. Feedback: CORRECT Because adult mood and anxiety comorbidities can be as high as 75%, they should be assessed at each follow-up visit. C) Metabolic syndrome. Feedback: INCORRECT Metabolic syndrome is associated with neuroleptic medications, not stimulants. D) Conduct disorders. Feedback: INCORRECT Conduct disorders are typically diagnosed in childhood. Points Earned: 0.0/1.0 Correct Answer(s): B Joe asks the nurse if he has to continue to take ADHD medication for the rest of his life. 25. How should the nurse response to Joe's question? A) "ADHD is a livelong condition that must be addressed." Feedback: INCORRECT This response could instill a sense of hopelessness in the client. B) "ADHD affects many areas of an individual's life." Feedback: INCORRECT The client is asking a legitimate question, not a summary of the impact of ADHD. C) "Psychotherapy that focuses on ADHD may help eliminate medication." Feedback: CORRECT This response offers a viable alternative to pharmacotherapy and Joe and discuss this with his HCP. D) "Only you can decide how long to continue on medication." Feedback: INCORRECT Although this response may empower the client, it does not offer alternatives. Points Earned: 0.0/1.0 Correct Answer(s): C Case Outcome Joe continues with follow-up visits to the clinic. He reports that he is following his medication regimen. During his senior year in college, Joe announces that he and his girlfriend will be getting married after graduation.
