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 B

Explanation

A reason: A client who has a new diagnosis of major depressive disorder. While clients with major depressive disorder need support, ACT is typically designed for clients with severe and persistent mental illnesses who require intensive, ongoing care.

B reason: A client who has repeated acute care admissions due to schizophrenia. Clients with schizophrenia who have frequent hospitalizations and difficulty managing their illness benefit from ACT. This program provides comprehensive, community-based care and support to reduce hospitalizations and improve quality of life.

C reason: A client who has requested family therapy following the death of a family member. Family therapy is more appropriate for addressing grief and loss. ACT is not typically indicated for clients dealing primarily with bereavement.

D reason: A client who has physical injuries following an incident of partner violence. Clients who have experienced partner violence may need crisis intervention, medical care, and counseling. ACT is not the primary referral for this situation unless the client also has a severe mental illness requiring intensive support.

A. Encourage the client to attend group therapy sessions. B. Allow the client to choose scheduled daily activities. C. Use simple words to describe procedures to the client. D. Avoid discussing topics that can trigger a panic attack.

Correct Answer is C

Explanation

A reason: Encourage the client to attend group therapy sessions. While group therapy can be beneficial for some clients, it may not be the best initial approach for those with panic disorder. Group settings can sometimes increase anxiety and trigger panic attacks.

B reason: Allow the client to choose scheduled daily activities. While allowing clients some control over their daily activities can be empowering, it does not directly address the symptoms of panic disorder. Structured interventions and therapeutic techniques are more effective.

C reason: Use simple words to describe procedures to the client. Using simple, clear language when explaining procedures helps reduce anxiety and prevent misunderstandings that could trigger a panic attack. This approach is particularly effective for clients with panic disorder, who may become easily overwhelmed.

D reason: Avoid discussing topics that can trigger a panic attack. While it is important to be mindful of topics that may cause distress, complete avoidance can prevent clients from learning to manage their triggers. Therapeutic approaches often involve gradual exposure to triggers in a controlled and supportive environment.

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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

Naxlex Comprehensive Predictor Exams

A nurse is reviewing the medical records of a group of clients. For which of the following clients should the nurse recommend a referral for assertive community treatment (ACT)?

Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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