A nurse is admitting a client to the mental health unit.

Exhibits

The nurse is developing a plan of care for the client. Which of the following interventions should the nurse include?

(Select all that apply.)

Choice A reason:

Expecting a child with ASD to communicate all needs verbally by discharge may not be realistic, as communication challenges are a core feature of ASD. Some individuals with ASD may never develop verbal communication skills and may rely on alternative methods of communication.

Choice B reason:

Participation in team sports may be challenging for a child with ASD due to difficulties with social interaction and sensory processing. While some children with ASD may enjoy and excel in sports, expecting participation in a team sport by day 4 may not account for the individual needs and preferences of the child.

Choice C reason:

Establishing trust with a caregiver is an important goal, but the timeframe of 5 days may be too short. Building trust can take time, especially for children with ASD who may have difficulty with new relationships and changes in their environment.

Choice D reason:

Focusing on self-care tasks is a realistic and practical goal for a child with ASD. With appropriate support and interventions, many individuals with ASD can learn to perform self-care tasks independently, although the level of independence will vary based on the individual's abilities and needs.

Choice A reason:

Asking the client "Why do you think you might have cancer when your diagnosis is a benign condition?" could be perceived as dismissive of the client's feelings. It's important for the nurse to acknowledge the client's concerns rather than questioning their rationale.

Choice B reason:

While it is true that discussing specific medical concerns with a provider is important, the statement "I think that's something you need to discuss with your provider" does not address the client's immediate emotional needs. The nurse should provide support and acknowledge the client's feelings before suggesting a discussion with the provider.

Choice C reason:

The response "I'm hearing that you are concerned that it might turn out that you have cancer" is an example of reflective listening. It shows that the nurse is actively listening and validating the client's concerns. This approach can help the client feel understood and supported during a stressful time.

Choice D reason:

Saying "I'm looking at your chart here and I don't see any reason for you to worry about that" may seem reassuring, but it does not validate the client's feelings. The nurse should acknowledge the client's fears and provide comfort, rather than simply referring to the medical facts.