A nurse is planning care for a school-aged child who has autism spectrum disorder and is nonverbal. Which of the following interventions should the nurse include in the plan of care?

Rationale for correct choices:

• Remaining neutral: The nurse should remain neutral to avoid reinforcing or escalating the client’s grandiose beliefs. This helps maintain trust and creates space for self-reflection without judgment.
• Explaining that the client is not entitled to play on a professional team: Gently addressing the client’s unrealistic expectations helps them understand the reality of their situation and fosters a more grounded perspective on their goals.

Rationale for incorrect choices:

• Questioning the client's abilities: Directly questioning the client's abilities could be seen as confrontational and may increase defensiveness. A more constructive approach would focus on challenging unrealistic beliefs.
• Challenging the client's feelings of grandiosity: Challenging grandiosity directly can make the client feel attacked. It’s better to educate and explain the reality of their expectations in a supportive way.
• Supporting the client's fear of abandonment: The client does not appear to express abandonment fears in this case. The issue is more related to grandiosity, so focusing on this would be more effective.
• Suggesting another sport: Suggesting a different sport might divert attention from the core issue—grandiosity. Addressing the client's distorted self-image is more important before offering alternatives.

A. "My boss fired me due to my frequent absence": This statement indicates a lack of support in the client's work environment, rather than a positive support system. Losing a job due to alcohol use suggests strained relationships and challenges in the client's social or professional life.
B. "My friends frequently drink alcohol, so I do not see them anymore": While the client is avoiding potentially harmful relationships, this statement indicates isolation rather than a supportive network.
C. "I have a sibling who attends Al-Anon": This statement indicates that the client has a family member actively involved in a support group (Al-Anon), which is designed for families and friends of individuals with alcohol use disorders. This suggests the client has a support system in place.
D. "I take care of my parent who has Wernicke-Korsakoff syndrome": While this indicates a sense of responsibility, it does not necessarily point to a supportive relationship. The client may be struggling with caregiving without the emotional or social support they need.