A nurse is performing an assessment on a 9-year-old child who had been diagnosed with Autism Spectrum Disorder. Which of the following findings would the nurse expect to observe?

The child is observed muttering to themselves, but denies having hallucinations.

The child freely walks up to strangers and engages in conversation.

The child makes poor eye contact and does not verbally respond to questions.

The child gets into fights with their teachers at school.

Answer and Explanation

The Correct Answer is C

A: While muttering to themselves can be observed in children with Autism Spectrum Disorder (ASD), it is not a definitive characteristic. Denying hallucinations is more related to psychotic disorders rather than ASD.

B: Children with ASD typically have difficulties with social interactions and are less likely to freely walk up to strangers and engage in conversation. This behavior is more characteristic of children without ASD.

C: Poor eye contact and lack of verbal response to questions are common observations in children with ASD. These behaviors reflect the social communication deficits that are central to the diagnosis of ASD.

D: Getting into fights with teachers is not a specific characteristic of ASD. While some children with ASD may exhibit challenging behaviors, this is not a defining feature of the disorder.

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Correct Answer is ["A","B","D"]

Explanation

A: Anxiety and agitation are common symptoms of delirium. Patients may become restless and anxious due to confusion and disorientation.

B: Disorganized thinking is a hallmark of delirium. Patients may have trouble maintaining a coherent line of thought and may exhibit incoherent speech.

C: Pain with bowel and bladder function is not a typical symptom of delirium. While discomfort can exacerbate delirium, it is not a defining characteristic.

D: Disorientation, particularly to time and place, is a key symptom of delirium. Patients often cannot accurately perceive their environment or understand their situation.

E: Overly friendly behaviors are not typically associated with delirium. Delirium usually involves confusion, agitation, and sometimes aggression rather than increased sociability.

A. Place difficulty in understanding on yourself: “I’m having trouble following you.” B. Let the patient think you understand to minimize the patient’s anxiety. C. Use reality testing to help the patient clarify their statements. D. Tell the patient they are not making any sense in order to set clear expectations.

Correct Answer is A

Explanation

A: Placing the difficulty in understanding on yourself by saying, “I’m having trouble following you,” is a therapeutic communication technique. It helps to reduce the patient’s anxiety and encourages them to clarify their thoughts without feeling judged. This approach fosters a supportive environment and can help the patient organize their thoughts better.

B: Letting the patient think you understand to minimize their anxiety is not an effective strategy. It can lead to further confusion and does not help the patient improve their communication. Honesty and clarity are important in therapeutic interactions.

C: Using reality testing to help the patient clarify their statements can be useful, but it may not be the best initial approach. It requires the patient to have some level of insight and ability to engage in reality testing, which may not be possible in severe cases of associative looseness.

D: Telling the patient they are not making any sense can be perceived as judgmental and may increase the patient’s anxiety and frustration. It is not a supportive or therapeutic approach and can hinder effective communication.

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A nurse is performing an assessment on a 9-year-old child who had been diagnosed with Autism Spectrum Disorder. Which of the following findings would the nurse expect to observe?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a patient diagnosed with delirium. The nurse would note these symptoms as consistent with delirium: Select all that apply.

Correct Answer is ["A","B","D"]

Explanation

The nurse is caring for a person displaying associative looseness. Which of the following would be the best strategy for the nurse to respond to associative looseness?

Correct Answer is A

Explanation

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