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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 D

Explanation

The correct answer is D:

Choice A reason: “If a dose is missed, double the next dose of medication.” This statement is incorrect. Doubling up on a dose can lead to an overdose and serious side effects. Patients are advised to take the missed dose as soon as they remember unless it’s almost time for the next dose.

Choice B reason: “This medication may increase your blood pressure.” Alprazolam is known to have a sedative effect, which can lower blood pressure rather than increase it. Therefore, this statement is not typically accurate.

Choice C reason: “Do not eat aged cheeses while taking this medication.” This dietary restriction is associated with monoamine oxidase inhibitors (MAOIs), which are a different class of medications used to treat depression. Alprazolam does not interact with tyramine-rich foods like aged cheeses, so this statement is not applicable.

Choice D reason: “Use a dependable form of contraception while taking this medication.” Alprazolam falls under FDA Pregnancy Category D, which means there is positive evidence of human fetal risk, but the potential benefits may warrant use in pregnant women despite the risks. Therefore, it is important to use reliable contraception to prevent pregnancy while taking this medication.

A. Set limits for the relationship. B. Engage in affectionate interactions with the client. C. Promote the use of transference by the client. D. Instruct the client on how he should behave.

Correct Answer is A

Explanation

The correct answer is choice A: Set limits for the relationship.

Choice A rationale:

Setting limits for the therapeutic relationship (Choice A) is an essential nursing action. Boundaries help create a safe and structured environment, ensuring that both the nurse and client maintain appropriate roles. Limits prevent overstepping boundaries that could compromise the therapeutic alliance.Setting limits for the relationship is an essential part of establishing a therapeutic relationship in a mental health setting. This helps to maintain professional boundaries and ensures that the relationship remains focused on the client’s needs and therapeutic goals.

Choice B rationale:

Engaging in affectionate interactions with the client (Choice B) is not appropriate in a therapeutic relationship. Professionalism and maintaining appropriate boundaries are crucial in psychiatric nursing. Affectionate interactions could blur the lines between the therapeutic relationship and personal relationships, potentially harming the client's progress.

Choice C rationale:

Promoting the use of transference by the client (Choice C) is not a suitable approach. Transference occurs when a client projects feelings and emotions onto the nurse based on past experiences. While it can be valuable to explore transference, actively promoting it could lead to confusion and misunderstandings in the therapeutic relationship.

Choice D rationale:

Instructing the client on how they should behave (Choice D) is contrary to the principles of a therapeutic relationship. The therapeutic relationship is client-centered, where the nurse supports the client's self-discovery and growth. Directing the client's behavior undermines their autonomy and inhibits their progress.

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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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