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

Lack of eye contact

Inability to play quietly

Constant spinning of a toy

Withdrawal from physical contact

Answer and Explanation

Correct Answer : A,C,D

A. Lack of eye contact: Difficulty with eye contact is a common characteristic of ASD. Many individuals with ASD may have challenges in establishing or maintaining eye contact during social interactions.

B. Inability to play quietly: Individuals with ASD may engage in repetitive or stereotyped behaviors, including noisy or disruptive play. However, the inability to play quietly is not universally present in all individuals with ASD.

C. Constant spinning of a toy: Repetitive or stereotyped movements, such as spinning objects or repetitive hand movements, are common behaviors observed in individuals with ASD. This behavior is often referred to as "stimming" or self-stimulatory behavior.

D. Withdrawal from physical contact: Sensory sensitivities are common in individuals with ASD, and some may be hypersensitive to touch or physical contact. As a result, they may withdraw from or avoid physical contact with others.

E. Repeated voiding in clothes: Repeated voiding in clothes is not typically considered a core feature of ASD. However, some individuals with ASD may have challenges with toileting, including difficulties with toilet training or sensory sensitivities related to bathroom routines.

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Correct Answer is A

Explanation

A. “If I drink alcohol I will become very sick.”: This statement accurately reflects the purpose of disulfiram. Disulfiram works by causing unpleasant physical symptoms, such as nausea, vomiting, and flushing, if alcohol is consumed, thereby deterring the individual from drinking.

B. “If I drink alcohol I will not be able to fall asleep.”: This statement does not accurately reflect the effects of disulfiram. Disulfiram does not typically affect sleep patterns directly; its effects are related to the ingestion of alcohol.

C. “If I drink alcohol will lose control of my inhibitions and say something I don’t mean.”: This statement does not accurately reflect the effects of disulfiram. Disulfiram does not directly affect inhibitions or speech patterns; its effects are related to physical symptoms caused by alcohol ingestion.

D. "If I drink alcohol will have severe mood swings.”: This statement does not accurately reflect the effects of disulfiram. Disulfiram does not typically cause mood swings; its effects are related to physical symptoms induced by alcohol ingestion.

A. A client who has a new diagnosis of major depressive disorder B. A client who has repeated acute care admissions due to schizophrenia C. A client who has requested family therapy following the death of a family member D. A client who has physical injuries following an incident of partner violence

Correct Answer is B

Explanation

A. A client who has a new diagnosis of major depressive disorder: While major depressive disorder can significantly impact functioning and may require treatment, it typically does not meet the criteria for ACT, which is primarily designed for individuals with severe and persistent mental illness.

B. A client who has repeated acute care admissions due to schizophrenia: Repeated acute care admissions due to schizophrenia suggest significant challenges in managing the illness and maintaining stability in the community. This client may benefit from the intensive support and comprehensive services provided by ACT to prevent future hospitalizations and promote community integration.

C. A client who has requested family therapy following the death of a family member: Family therapy may be an appropriate intervention for supporting this client's grieving process and addressing family dynamics. However, it does not necessarily indicate the need for ACT, which is focused on individuals with severe and persistent mental illness.

D. A client who has physical injuries following an incident of partner violence: While this client may require support and interventions to address the effects of partner violence, it does not specifically indicate the need for ACT unless there are underlying severe and persistent mental health issues contributing to the situation.

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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? (Select all that apply)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing teaching to a client who has a prescription for disulfiram. Which of the following client statements indicates an understanding of the teaching?

Correct Answer is A

Explanation

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

A nurse is caring for a client who has bipolar disorder. The client says to the nurse. "Give me your pen to cut the pain out of my chest. The nurse should identify that the client is at risk for which of the following?

A nurse is using de-escalation techniques with a client who has become verbally aggressive with a staff member. Which of the following actions should the nurse take?

A nurse is planning to teach a client who is taking lithium. Which of the following should the nurse include in the teaching as adverse effects of therapeutic lithium level?

A nurse on a mental health unit is leading a group therapy session for a group of clients. Which of the following statements should the nurse expect from a client who has illness anxiety disorder?

A charge nurse is providing education to a group of newly-licensed nurses about the rights of clients who are involuntarily admitted. Which of the following responses by a newly-licensed nurse indicates understanding of the teaching?

A nurse in an acute care facility is assessing a client who has schizophrenia. The client states. "Walk tall broom short dag bell." The nurse should document the client's speech as which of the following speech patterns?

A nurse in an urgent-care clinic is caring for a school-age child who has several visible bruises. The child's parent states. "My partner got fret today and came home angry. I don't think this will happen again" Which of the following responses should the nurse make?

A nurse is creating a plan of care for a newly admitted client who has obsessive-compulsive disorder. Which of the following interventions should the nurse include?