A nurse is caring for a 4-year-old child who has autism spectrum disorder. Which of the following behaviors should the nurse expect?

Lack of eye contact.

Inability to play quietly.

Constant spinning of a toy.

Withdrawal from physical contact.

Repeated voicing in clothes.

Answer and Explanation

Correct Answer : A,C,D

A reason: Lack of eye contact. Children with autism spectrum disorder (ASD) often exhibit reduced or lack of eye contact, which can be a key indicator of social communication difficulties associated with ASD.

B reason: Inability to play quietly. While some children with autism might exhibit hyperactive behavior, an inability to play quietly is not a specific characteristic of ASD. It can be seen in various conditions, including attention deficit hyperactivity disorder (ADHD).

C reason: Constant spinning of a toy. Repetitive behaviors, such as spinning objects, are common in children with ASD. These behaviors provide sensory input and can be calming for the child.

D reason: Withdrawal from physical contact. Children with ASD often withdraw from physical contact due to sensory sensitivities. They might find certain touches uncomfortable or overwhelming.

E reason: Repeated voicing in clothes. Repeating phrases or sounds, known as echolalia, is common in ASD, but "repeated voicing in clothes" does not accurately describe this behavior. It seems like a typographical error.

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Correct Answer is C

Explanation

A reason: Administer a sedative medication. While administering a sedative may be necessary to calm the client, it is not the first step. The nurse should initially attempt to de-escalate the situation using non-pharmacological interventions.

B reason: Perform a debriefing with the staff. Debriefing with the staff is important after the situation is under control, but it is not the immediate priority. The focus should first be on addressing the client's behavior and emotions.

C reason: Acknowledge the client's emotions. Acknowledge the client's emotions to de-escalate the situation and help the client feel heard and understood. This can reduce the immediate risk of violence or self-harm.

D reason: Place the client in restraints. Restraints should be used as a last resort when other interventions have failed and there is an immediate risk of harm. The nurse should first try to calm the client through verbal and emotional support.

A. Use detailed explanations when providing education to the client. B. Maintain a stimulating environment for the client. C. Provide the client with a structured schedule of daily activities. D. Limit time for rituals to 30 minutes each day.

Correct Answer is C

Explanation

A reason: Use detailed explanations when providing education to the client. While providing clear and concise explanations is important, overly detailed explanations may overwhelm a client with OCD. Simplifying communication can be more effective in reducing anxiety.

B reason: Maintain a stimulating environment for the client. A stimulating environment can increase anxiety and trigger obsessive-compulsive behaviors in clients with OCD. A calm and structured environment is more beneficial.

C reason: Provide the client with a structured schedule of daily activities. A structured schedule helps clients with OCD manage their time and reduces the likelihood of engaging in compulsive behaviors. It provides a sense of predictability and control, which can reduce anxiety.

D reason: Limit time for rituals to 30 minutes each day. While limiting the time for rituals is a goal, setting such a specific limit might initially increase anxiety. A more gradual approach to reducing ritual time, integrated within a structured schedule, is often more effective.

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A nurse is caring for a 4-year-old child who has autism spectrum disorder. Which of the following behaviors should the nurse expect?

Nursing Test Bank

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