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 A

Explanation

A reason: A nurse did not clarify a client's prescription that was difficult to read, resulting in a medication error. This scenario describes negligence, an unintentional tort, where the nurse failed to act with the standard of care expected, leading to a medication error.

B reason: A nurse posted private information on social media about a client who has a substance use disorder. Posting private information without consent is an intentional tort, specifically a breach of confidentiality and invasion of privacy.

C reason: A nurse placed a client in mechanical restraints without obtaining a prescription, resulting in injury. This scenario describes an intentional tort, as the nurse intentionally restrained the client without proper authorization, leading to harm.

D reason: A nurse threatened a client with physical harm after the client became verbally abusive to staff members. Threatening a client with harm is an intentional tort, specifically assault, which involves an intentional act of creating apprehension of harmful contact.

A. Document the client's behavior once every hour. B. Keep the client in restraints until the prescription expires. C. Conduct a debriefing regarding the client with the unit staff. D. Request an evaluation of the client within 12 hours of application of restraints.

Correct Answer is C

Explanation

A reason: Document the client's behavior once every hour. While documenting the client's behavior is important, it should be done more frequently than once every hour. Monitoring should be continuous to ensure the client's safety.

B reason: Keep the client in restraints until the prescription expires. Restraints should be used for the shortest duration necessary to ensure safety, not just until the prescription expires. Regular assessments are needed to determine if they can be removed earlier.

C reason: Conduct a debriefing regarding the client with the unit staff. Debriefing with the unit staff helps ensure everyone is informed about the client's condition, the reasons for using restraints, and the plan for ongoing care. This promotes a team approach to managing the client's behavior.

D reason: Request an evaluation of the client within 12 hours of application of restraints. An evaluation should be conducted much sooner than 12 hours, typically within an hour of applying restraints, to assess the client's physical and mental status and determine if continued use is justified.

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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 charge nurse is planning an in-service for newly licensed nurses on tort law in mental health care. Which of the following scenarios should the charge nurse provide as an example of an unintentional tort?

Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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