A nurse assesses a 3-year-old diagnosed with an autism spectrum disorder. Which finding is associated with the child disorder? The child
has occasional toileting accidents.
interrupts or intrudes on others.
cries when separated from a parent.
continuously rocks in place for 30 minutes.
The Correct Answer is D
A. Occasional toileting accidents may be developmentally normal at age 3 and are not specific to autism spectrum disorder (ASD).
B. Interrupting or intruding on others is more consistent with ADHD than autism.
C. Crying when separated from a parent is typical of separation anxiety, not autism.
D. Repetitive motor behaviors such as rocking, hand-flapping, or spinning are characteristic of autism spectrum disorder. These stereotypical movements are used for self-stimulation and regulation.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "I hate all of you!" –This reflects the patient’s anger and hostility, which is expected after being restrained. While it requires therapeutic communication, it does not signal a medical emergency.
B. "The other patient started the fight." – This statement is defensive and attempts to shift blame. Although it provides insight into the patient’s thought process, it is not urgent from a physiological standpoint.
C. "You wait until I tell my lawyer." – This reflects frustration and a threat of legal action. It is important for documentation and de-escalation but does not require immediate clinical intervention.
D. "My fingers are tingly." – This is the highest priority because it indicates impaired circulation or nerve compression related to the restraints. Tingling, numbness, coolness, or pallor are warning signs that restraints are too tight or causing neurovascular compromise. This can lead to permanent injury if not corrected promptly.
Correct Answer is A
Explanation
A. Using silence allows the patient time to process thoughts and feelings, encourages introspection, and can facilitate deeper communication during interviews.
B. While prolonged silence can sometimes make patients uncomfortable, its intentional and therapeutic use is beneficial when appropriately timed.
C. Reflecting or paraphrasing communicates understanding; silence alone does not confirm comprehension.
D. In therapeutic communication, the nurse does not have to immediately fill silence; allowing moments of quiet can be purposeful.
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