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

Delayed language development.

Consistent limit testing.

Spinning a toy repetitively.

Short attention span.

Ritualistic behavior.

Answer and Explanation

Correct Answer : A,C,E

The correct answers are: a. Delayed language development, c. Spinning a toy repetitively, and e. Ritualistic behavior.

Explanation:

Choice A Rationale: Delayed language development is a common characteristic of autism spectrum disorder (ASD). Children with ASD may exhibit difficulties in acquiring and using language appropriately, including delayed onset of speech, limited vocabulary, and challenges with syntax and pragmatics. This delay can significantly impact their ability to communicate effectively and engage in social interactions. Early intervention strategies, such as speech therapy and alternative communication methods, are often implemented to support language development in children with ASD.

Choice B Rationale: Consistent limit testing, characterized by challenging authority and testing boundaries, is not a hallmark feature of autism spectrum disorder (ASD). While some children with ASD may exhibit behaviors that appear oppositional or defiant, such behaviors are more commonly associated with other conditions such as oppositional defiant disorder (ODD) or conduct disorder (CD). ASD is primarily characterized by deficits in social communication and interaction, along with restricted, repetitive patterns of behavior, interests, or activities.

Choice C Rationale: Spinning a toy repetitively is a stereotypical behavior often observed in children with autism spectrum disorder (ASD). Repetitive behaviors, including spinning objects, rocking back and forth, or hand-flapping, are considered one of the core diagnostic criteria for ASD. These behaviors serve various functions for individuals with ASD, including sensory stimulation, self-soothing, or reducing anxiety. While repetitive behaviors can vary widely among individuals with ASD, they are a recognizable feature of the disorder.

Choice D Rationale: A short attention span is not a specific characteristic of autism spectrum disorder (ASD). While some children with ASD may exhibit difficulties with attention and focus, particularly in tasks that do not align with their specific interests or preferences, attention deficits are not universal among individuals with ASD. Additionally, attention difficulties are not considered a primary diagnostic criterion for ASD. Other neurodevelopmental disorders, such as attention-deficit/hyperactivity disorder (ADHD), are more commonly associated with impairments in attention and concentration.

Choice E Rationale: Ritualistic behavior, such as engaging in specific routines or repetitive actions, is a hallmark feature of autism spectrum disorder (ASD). Children with ASD often demonstrate a preference for predictability and sameness in their environment, leading to the development of rigid routines or rituals. These behaviors can serve as a source of comfort or security for individuals with ASD, providing structure and predictability in an otherwise unpredictable world. Ritualistic behaviors can manifest in various forms, such as insisting on following the same daily schedule, arranging objects in a specific order, or becoming distressed when routines are disrupted.

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Correct Answer is ["A","B","C","E"]

Explanation

Choice A rationale:

Tachycardia (rapid heart rate) is a potential physical symptom of alcohol withdrawal. When alcohol-dependent individuals suddenly stop or reduce their alcohol intake, it can lead to increased sympathetic nervous system activity, resulting in elevated heart rate.

Choice B rationale:

Tremors (shakes) are common during alcohol withdrawal due to the suppression of the central nervous system by alcohol. Abrupt cessation of alcohol can lead to overactivity in the nervous system, resulting in tremors.

Choice C rationale:

Hallucinations can occur during alcohol withdrawal and are usually visual or tactile in nature. These hallucinations are often referred to as alcoholic hallucinosis and can be distressing for the individual experiencing them.

Choice E rationale:

Seizures can be a severe consequence of alcohol withdrawal. Known as alcohol withdrawal seizures, these episodes can occur within the first 48 hours after cessation of heavy alcohol consumption and are attributed to the hyperexcitability of the central nervous system.

Choice D rationale:

Hypotension (low blood pressure) is not typically associated with alcohol withdrawal. In fact, alcohol withdrawal often leads to an increase in blood pressure and heart rate due to the hyperactivity of the sympathetic nervous system.

A. "You are not responsible for your mother's stroke, but many people in your situation feel this way.” B. "Your mother will be fine. You shouldn't worry so much.” C. "Why do you blame yourself? You could not have prevented the stroke.” D. "So, it seems that you feel responsible for what happened to your mother.”

Correct Answer is D

Explanation

The correct answer is choiced. "So, it seems that you feel responsible for what happened to your mother.”

Choice A rationale:This response attempts to reassure the son but may come off as dismissive of his feelings. It does not encourage further discussion or exploration of his emotions.

Choice B rationale:This response is overly reassuring and dismisses the son’s feelings of guilt. It does not address his emotional state or encourage him to express his concerns.

Choice C rationale:This response questions the son’s feelings directly, which might make him defensive. It does not validate his emotions or encourage him to talk more about his feelings.

Choice D rationale:This response acknowledges the son’s feelings and encourages him to express his emotions. It is a therapeutic communication technique that helps the son feel heard and understood, which is crucial in providing emotional support.

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

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Naxlex Comprehensive Predictor Exams

A nurse on the medical unit is admitting a client with a history of alcohol use disorder. The nurse is aware that which of the following are potential physical symptoms of alcohol withdrawal? (Select all that apply.).

Correct Answer is ["A","B","C","E"]

Explanation

A nurse is caring for an older adult client diagnosed with a cerebrovascular accident and has right-sided paralysis and aphasia. The client's son tells the nurse it is his fault because he did not insist that his mother live with him. Which of the following responses should the nurse make?

Correct Answer is D

Explanation

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