A nurse is planning care for an adolescent who has autism spectrum disorder. Which of the following outcomes should the nurse include in the plan of care?
Initiates social interactions with caregivers
Meets own needs without manipulating others
Changes behavior as a result of peer pressure
Acknowledges that his delusions are not real
The Correct Answer is B
A. Initiates social interactions with caregivers:
While improving social interactions is a valuable goal, individuals with autism spectrum disorder (ASD) often struggle with social communication. Initiating social interactions can be challenging for them due to difficulties in understanding social cues and reciprocal communication. Setting this goal might be too ambitious without considering the individual's specific abilities and progress in social skills development.
B. Meets own needs without manipulating others:
This is a suitable goal for an individual with ASD. Many individuals with ASD can learn self-help skills and independence, such as personal hygiene, dressing, and basic communication, allowing them to meet their own needs. Teaching them to meet their needs without resorting to manipulation is important for fostering independence and appropriate social behavior.
C. Changes behavior as a result of peer pressure:
Individuals with ASD often struggle with understanding and responding to social cues, making it difficult for them to change their behavior based on peer pressure. Setting a goal related to conforming to peer pressure may not be realistic or developmentally appropriate for someone with ASD. Instead, interventions should focus on developing appropriate social skills and fostering self-confidence.
D. Acknowledges that his delusions are not real:
Delusions, which are false beliefs that are strongly held despite evidence to the contrary, are not typically a part of ASD. ASD is characterized by challenges in social communication, repetitive behaviors, and restricted interests. Setting a goal related to delusions is not relevant to the core features of ASD and may indicate a misunderstanding of the disorder's characteristics. Goals should be focused on addressing the specific challenges associated with ASD, such as social communication and sensory sensitivities.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Request that the client's partner sign the consent form:
While involving the client's partner might offer emotional support and facilitate communication, legal and ethical guidelines typically require the informed consent of the individual undergoing the procedure. Having a partner sign the form without the client's explicit consent would not adhere to these standards.
B. Inform the client about the risks of refusing ECT:
Educating the client about the potential risks and benefits of ECT, as well as discussing alternative treatments, is a crucial step in the informed consent process. However, merely informing the client does not replace the need for the client to provide explicit, written consent for the procedure to be performed legally and ethically.
C. Cancel the scheduled ECT procedure:
This is the correct action. Without the client's signed consent, the procedure cannot proceed. Canceling the ECT procedure respects the client's autonomy and adheres to legal and ethical standards surrounding informed consent. The healthcare team should continue to engage with the client, addressing any concerns and questions, to obtain their informed and voluntary consent before rescheduling the procedure if the client chooses to proceed.
D. Proceed with preparation for ECT based on implied consent:
Implied consent is not sufficient for significant medical procedures such as ECT. Implied consent implies agreement based on actions or behavior rather than explicit, informed agreement. For procedures like ECT, it is essential to have documented, explicit, and voluntary consent from the client before proceeding. Relying solely on implied consent would not meet the ethical and legal requirements for informed consent.
Correct Answer is D
Explanation
A. Denial:
Denial is a defense mechanism in which a person refuses to accept reality or acknowledge the existence of something that is evident to others. For example, a person diagnosed with a serious illness might deny that they are ill or refuse to believe the diagnosis. In this scenario, the client is not denying a reality; he is expressing anger and directing it toward the nurse.
B. Compensation:
Compensation is a defense mechanism where an individual overachieves in one area to compensate for real or imagined deficiencies in another area. For instance, someone who feels intellectually inferior might excel in sports to compensate for their perceived inadequacy. This is not applicable to the client's situation in the scenario provided.
C. Rationalization:
Rationalization involves providing logical or reasonable explanations to justify behaviors or feelings that might otherwise be unacceptable. For instance, a person might rationalize a failure by blaming external factors rather than accepting personal responsibility. In the scenario, the client is not offering rationalizations but is expressing direct anger.
D. Displacement:
Displacement occurs when emotions, especially anger or frustration, are redirected from the original source to a less threatening target. For example, a person who is angry with their boss might come home and take out their frustration on their family members. In the given situation, the client is displacing his anger from his partner onto the nurse, asking her to leave, making displacement the most appropriate choice.
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