A nurse is caring for an adolescent client who has a history of depression and suicidal ideation. Which of the following client statements should the nurse identify as requiring further intervention?

B. Continuous rocking of the body, is a repetitive behavior commonly observed in children with ASD. This behavior, known as stereotypy or self-stimulatory behavior, involves repetitive movements such as rocking, hand-flapping, or spinning, which are often self-soothing or self- regulating in nature.

A. Some children with ASD may struggle with tasks involving language comprehension or processing, such as reading instructions. However, this difficulty is not universal among all children with ASD and can vary depending on individual strengths and challenges.

C. Some children with ASD may have challenges with language and communication skills but including spelling, this difficulty is not specific to ASD.

D. Memory difficulties can be associated with various neurodevelopmental conditions, including ASD, but they are not a defining characteristic of ASD.

C. The nurse should address the client's inappropriate and boundary-crossing behavior first. The client's statement, "Kiss me baby! You know you want to!" is suggestive and inappropriate in a professional healthcare setting. It indicates a lack of understanding or disregard for appropriate social boundaries and may be a manifestation of the client's serious mental illness.

A, B, D- While the client's vital signs (blood pressure, heart rate, respiratory rate, and temperature) and clothing choice (wearing a heavy coat and scarf in warm weather) may be important to assess and address, the immediate priority is to address the client's inappropriate behavior and ensure a safe and therapeutic environment for both the client and the nurse.