Essentials of Psychiatric Mental Health Nursing 6th Edition by Mary Townsend

تمرين 1

Jimmy, age 9, has been admitted to the child psychiatric unit with a diagnosis of Attention-Deficit/Hyperactivity Disorder. He has been unmanageable at school and at home and was recently suspended from school for continuous disruption of his class. He refuses to sit in his chair or do his work. He yells out in class, interrupts the teacher and the other students, and lately has become physically aggressive when he cannot have his way. He was suspended after hitting his teacher when she asked him to return to his seat. Jimmy's mother describes him as a restless and demanding baby who grew into a restless and demanding toddler. He has never gotten along well with his peers. Even as a small child, he would take his friends' toys away from them or bite them if they tried to hold their own with him. His 5-year-old sister is afraid of him and refuses to be alone with him. During the nurse's intake assessment, Jimmy paced the room or rocked in his chair. He talked incessantly on a superficial level and jumped from topic to topic. He told the nurse that he did not know why he was there. He acknowledged that he had some problems at school but said that was only because the other kids picked on him and the teacher did not like him. He said he got into trouble at home sometimes but that was because his parents liked his little sister better than they liked him. The physician has ordered methylphenidate, 5 mg twice a day, for Jimmy. His response to this order is, "I'm not going to take drugs. I'm not sick!"
What are the pertinent assessment data to be noted by the nurse?