A parent describes a 3-year-old child in constant motion and is unable to sit still during story time. The parent is concerned about this behavior. Which nursing response indicates an appropriate evaluation of the situation?

A. "This child has symptoms of the early stages of autistic disorder.": Autism spectrum disorder typically presents with deficits in social communication, repetitive behaviors, and restricted interests rather than hyperactivity alone. Constant motion by itself does not indicate autism.

B. "This child's behavior indicates possible symptoms of oppositional defiant disorder.": Oppositional defiant disorder involves persistent patterns of defiant, disobedient, and hostile behavior toward authority figures. Hyperactivity or inability to sit still is not a defining feature.

C. "This child has symptoms of attention deficit hyperactivity disorder.": While hyperactivity is a hallmark of ADHD, a diagnosis cannot be made based on a single observation or parental report. Comprehensive evaluation over time and across settings is required.

D. "This child's behavior must be evaluated according to developmental norms.": Children’s activity levels vary with age and developmental stage. Comparing behavior to developmental expectations allows identification of typical versus concerning patterns and determines if further assessment is warranted.

A. Involve family in treatment: Family involvement helps address relational stressors and improves communication and support systems. Education and collaboration with caregivers can reduce triggers for self-harm and reinforce healthy coping strategies. Inclusion is guided by safety, consent, and therapeutic goals.

B. Encourage secrecy to maintain trust: Encouraging secrecy can increase risk by limiting safety planning and preventing appropriate monitoring. Nursing care emphasizes transparency, safety, and appropriate information sharing when self-harm is present. Trust is built through honest communication and protective collaboration.

C. Refer for dialectical behavior therapy (DBT): DBT is an evidence-based approach for adolescents who engage in self-injury. It focuses on emotion regulation, distress tolerance, interpersonal effectiveness, and mindfulness. Referral supports development of safer coping skills.

D. Teach alternative coping strategies: Teaching skills such as grounding, journaling, sensory modulation, or reaching out for support provides practical alternatives to self-harm. These strategies target emotional regulation and reduce reliance on injurious behaviors.