A nurse is developing the initial care plan for a client who is ...

[Zulu123]

A nurse is developing the initial care plan for a client who is prescribed a central nervous system stimulant for the treatment of ADHD. Which nursing diagnoses will most likely be a part of this care plan?
 
  Standard Text: Select all that apply.
  1. Family Processes, Interrupted
  2. Development: Delayed, Risk for
  3. Sleep Pattern, Disturbed
  4. Gas Exchange, Impaired
  5. Nutrition, Imbalanced: Less than Body Requirements

Question 2

An infant in the neonatal intensive care unit is prescribed caffeine (Cafcit) IV as treatment for apnea. Which medical orders should the nurse plan for, based on the addition of this medication?
 
  Standard Text: Select all that apply.
  1. Blood glucose measurements every 2 hours
  2. Bilirubin measurement daily
  3. Seizure precautions
  4. Deep tendon reflex monitoring every 4 hours
  5. Skin assessment every 4 hours

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Answer to Question 1

Correct Answer: 1,2,3
Rationale 1: ADHD and the challenges it presents often cause stress and strain in the family.
Rationale 2: Many of the drugs used to treat ADHD result in a delay of development.
Rationale 3: Many of the stimulant medication used to treat ADHD result in irritability and insomnia.
Rationale 4: Stimulant drugs do not have an effect on gas exchange.
Rationale 5: It is likely that these drugs would result in weight loss.
Global Rationale: ADHD and the challenges it presents often cause stress and strain in the family. Many of the drugs used to treat ADHD result in a delay of growth and development. Many of the stimulant medication used to treat ADHD result in irritability and insomnia. Stimulant drugs do not have an effect on gas exchange. It would be likely that these drugs would result in weight loss.

Answer to Question 2

Correct Answer: 2,3
Rationale 1: While caffeine should be used with caution in clients with diabetes, there is no indication that blood glucose should be monitored every 2 hours.
Rationale 2: One of the serious adverse effects of using Cafcit in newborns is the development of kernicterus. Increasing bilirubin measurements indicate potential for development of kernicterus.
Rationale 3: One of the serious adverse effects of using Cafcit in newborns is the development of seizures.
Rationale 4: Deep tendon reflexes are monitored to see if paresthesia is developing. Paresthesia is not an adverse effect related to Cafcit.
Rationale 5: Cafcit does not result in skin disorders.
Global Rationale: One of the serious adverse effects of using Cafcit in newborns is the development of kernicterus. Increasing bilirubin measurements indicate potential for development of kernicterus. One of the serious adverse effects of using Cafcit in newborns is the development of seizures. While caffeine should be used with caution in clients with diabetes, there is no indication that blood glucose should be monitored every 2 hours. Deep tendon reflexes are monitored to see if paresthesia is developing. Paresthesia is not an adverse effect related to Cafcit. Cafcit does not result in skin disorders.

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