A nurse is caring for a client diagnosed with autism spectrum disorder (ASD). Which of the following assessment findings should the nurse recognize to be associated with ASD?

Echolalia

Ambivalence

Expressive affect

Associative looseness

Answer and Explanation

The Correct Answer is A

A. Echolalia: Echolalia, the repetition of words or phrases spoken by others, is a common characteristic of autism spectrum disorder. It can be part of the individual’s attempt to communicate or self-stimulate and may be indicative of difficulties in expressive language development.

B. Ambivalence: Ambivalence, the state of having mixed feelings or contradictory ideas about something or someone, is more commonly associated with conditions like schizophrenia, not ASD.

C. Expressive affect: Individuals with ASD often have difficulties with expressive affect, meaning they may show limited emotional expression, which contrasts with the term "expressive affect" suggesting full emotional expression.

D. Associative looseness: Associative looseness, a symptom where a person’s thoughts are disconnected and fragmented, is more characteristic of schizophrenia than ASD.

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Correct Answer is C

Explanation

A. "I just don't remember what I did this morning." This statement reflects an inability to recall the events of the morning, which is a common symptom in Alzheimer's disease but does not constitute confabulation. It simply indicates memory loss.

B. "This morning, this morning, this morning..." Repetition of words or phrases can indicate a language or communication issue often seen in Alzheimer's disease but is not an example of confabulation. It may reflect confusion or perseverance.

C. "It was good. The Queen of England visited me there." Confabulation involves the creation of false memories or statements to fill in gaps in memory. The client's statement about the Queen of England visiting is a fabricated or distorted memory and is an example of confabulation. This choice is correct.

D. "Snip, snap. Take a nap." This phrase is nonsensical and may indicate disorganized thinking or speech, which can occur in Alzheimer's disease, but it is not an example of confabulation. It does not fill a memory gap with a fabricated story. Therefore, this choice is incorrect.

A. Follow the established protocol for reporting suspected child abuse or neglect to the appropriate authorities. B. Convince the child to disclose the cause of the injuries through gentle questioning and persuasion. C. Respect the child's privacy and wait for them to share information about the injuries voluntarily. D. Document and discuss the observations with the child's teacher to gather more information.

Correct Answer is A

Explanation

A. Follow the established protocol for reporting suspected child abuse or neglect to the appropriate authorities: This is the correct approach according to child protection guidelines. School personnel are mandated reporters and must report suspected abuse or neglect to protect the child's safety.

B. Convince the child to disclose the cause of the injuries through gentle questioning and persuasion: This approach can inadvertently pressure the child and is not recommended as it may lead to further distress or inaccurate information.

C. Respect the child's privacy and wait for them to share information about the injuries voluntarily: While respecting privacy is important, child protection takes precedence when there are signs of abuse or neglect.

D. Document and discuss the observations with the child's teacher to gather more information: While documentation is important, it should not delay reporting suspected abuse or neglect to the appropriate authorities.

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A nurse is caring for a client diagnosed with autism spectrum disorder (ASD). Which of the following assessment findings should the nurse recognize to be associated with ASD?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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