A nurse in an outpatient mental health facility is assessing a child who has autism spectrum disorder. Which of the following manifestations should the nurse expect?

Strict adherence to routines

Difficulty paying attention to tasks

Disobedience to authority figures

Excessive anxiety when separated from parents

Answer and Explanation

The Correct Answer is A

- A. This choice is correct because a child who has autism spectrum disorder often exhibits strict adherence to routines and rituals, and may become distressed or agitated when there are changes or disruptions to their usual patterns.

- B. This choice is incorrect because difficulty paying attention to tasks is not a specific manifestation of autism spectrum disorder, but rather a common symptom of attentiondeficit/hyperactivity disorder (ADHD). A child who has autism spectrum disorder may have difficulty focusing on tasks that are not of interest to them, but may also show intense concentration on tasks that are of interest to them.

- C. This choice is incorrect because disobedience to authority figures is not a specific manifestation of autism spectrum disorder, but rather a common behavior problem in children and adolescents. A child who has autism spectrum disorder may have difficulty understanding social cues and expectations, but may also show compliance and cooperation when given clear instructions and positive reinforcement.

- D. This choice is incorrect because excessive anxiety when separated from parents is not a specific manifestation of autism spectrum disorder, but rather a common symptom of separation anxiety disorder. A child who has autism spectrum disorder may have difficulty forming attachments and expressing emotions, but may also show affection and attachment to familiar people.

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Correct Answer is ["B","C","E","F"]

Explanation

The four findings that require follow-up are B, C, E, and F.

Rationale:

Blood pressure: A normal blood pressure for an adolescent is 110/70 mm Hg. The question does not provide the adolescent's blood pressure, so it cannot be determined if it requires followup or not.
Capillary refill: A normal capillary refill time is less than 2 seconds. A prolonged capillary refill time indicates impaired blood flow to the extremity, which could be due to vascular injury, compartment syndrome, or shock.
Pedal pulse: A normal pedal pulse is +2 or +3. A weak pedal pulse (+1) indicates reduced blood flow to the extremity, which could be due to vascular injury, compartment syndrome, or shock.
Heart rate: A normal heart rate for an adolescent is 60 to 100 beats per minute. The question does not provide the adolescent's heart rate, so it cannot be determined if it requires follow-up or not.
Skin temperature: A normal skin temperature is warm and dry. A cool skin temperature indicates reduced blood flow to the extremity, which could be due to vascular injury, compartment syndrome, or shock.
Pain: A pain level of 10 on a scale of 0 to 10 indicates severe pain that needs to be managed with appropriate analgesics and nonpharmacological interventions.

A. Respiratory alkalosis B. Metabolic alkalosis C. Respiratory acidosis D. Metabolic acidosis

Correct Answer is C

Explanation

Respiratory acidosis.

Rationale:

A. Incorrect. The client does not have respiratory alkalosis because respiratory alkalosis is characterized by a low PaCO2 (less than 35 mm Hg) and a high pH (greater than 7.45).
B. Incorrect. The client does not have metabolic alkalosis because metabolic alkalosis is characterized by a high HCO3 (greater than 26 mEq/L) and a high pH (greater than 7.45). - C. Correct. The client has respiratory acidosis because respiratory acidosis is characterized by a high PaCO2 (greater than 45 mm Hg) and a low pH (less than 7.35).
D. Incorrect. The client does not have metabolic acidosis because metabolic acidosis is characterized by a low HCO3 (less than 22 mEq/L) and a low pH (less than 7.35).

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A nurse in an outpatient mental health facility is assessing a child who has autism spectrum disorder. Which of the following manifestations should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["B","C","E","F"]

Explanation

A nurse is reviewing the ABG values of a client. The client has a pH of 7.2, PaCO2 of 60 mm Hg, and HCO3 of 25 mEq/L. The nurse should identify that the client has which of the following acid-base imbalances?

Correct Answer is C

Explanation

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