The nurse is reviewing the records of a child diagnosed with autistic spectrum disorder (ASD). Which of the following client outcomes should the nurse recognize as realistic for a client diagnosed with ASD?

The client will establish trust with at least one caregiver by day 5.

The client will participate with peers in a team sport by day 4.

The client will communicate all needs verbally by discharge.

The client will perform most self-care tasks independently.

Answer and Explanation

The Correct Answer is D

Choice A rationale:

Establishing trust with a caregiver in just five days is a challenging and unrealistic expectation for a child diagnosed with autistic spectrum disorder (ASD). Building trust takes time, especially for individuals with ASD who may struggle with social interactions and forming connections.

Choice B rationale:

Participating in a team sport with peers by day 4 might be too ambitious for a child with ASD. Children with ASD often require gradual exposure and support to engage in social activities, and such rapid participation might lead to anxiety and discomfort.

Choice C rationale:

While communication goals are important for children with ASD, expecting them to communicate all needs verbally by discharge might not be realistic. Many children with ASD use alternative forms of communication, such as gestures or assistive devices, which should also be considered as valid modes of expression.

Choice D rationale:

The realistic outcome for a child diagnosed with ASD is that they will perform most self-care tasks independently. ASD often affects social and communication skills, but children can learn and develop the ability to manage self-care tasks with proper support and intervention. This outcome aligns with the developmental trajectory of children with ASD.

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Correct Answer is C

Explanation

Answer: c. Document the client's verbatim statements.

Here's why the other options are wrong:

a. Ask the client for permission to take photographs:While photographs may be collected as evidence later, it should not be the first priority. The priority is to focus on patient care and emotional well-being.
b. Provide community sexual assault support contacts:Offering support resources is important, but documenting the details of the assault is crucial for forensic and legal purposes, and should come first.
d. Determine any physical signs of injury:Looking for physical injuries is important, but documenting the client's account should come first. This ensures the client's narrative is captured accurately and can be referred to later.

Documenting the client's verbatim statements is the most important initial action because:

It preserves the client's account of the assault in their own words.
It allows for accurate reporting and investigation.
It can be used as evidence in legal proceedings.

Here are some supporting points:

The Rape, Abuse & Incest National Network (RAINN):"Law enforcement will need to take a detailed statement about the assault, and a medical professional will likely perform a physical exam. Be prepared to answer questions about what happened." [1]
The National Sexual Assault Hotline:"Law enforcement will want to get a statement from you as soon as possible after the assault. Try to remember the details of the assault as clearly as you can." [2]

In conclusion, while all the other options are important aspects of caring for a sexual assault survivor, documenting the client's verbatim statements is the most critical initial action for a nurse to take in the emergency department setting.

A. "Why did you make the choice to behave negatively?” B. "You need to calm down and forgive me before discussing this matter any further.” C. "You were made aware of the consequences of negative behavior so you better go to your room.” D. "I understand that you are angry. However, I followed the appropriate protocol.”

Correct Answer is D

Explanation

Choice A rationale:

This response uses a confrontational tone and places blame on the client for their behavior, which is not an example of assertive communication. It can potentially escalate the situation and hinder effective communication.

Choice B rationale:

This statement is authoritarian in nature, using phrases like "you need to" and "forgive me," which can further upset the client and create a power struggle. It lacks empathy and understanding, making it ineffective for assertive communication.

Choice C rationale:

While this response acknowledges the consequences of the client's negative behavior, it uses commanding language ("you better go to your room"), which can be perceived as aggressive and may escalate the situation instead of facilitating effective communication.

Choice D rationale:

This statement is the most effective example of assertive communication. It acknowledges the client's feelings ("I understand that you are angry") while also asserting the nurse's adherence to protocol. This response demonstrates empathy, understanding, and a willingness to address the client's emotions in a non-confrontational manner.

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The nurse is reviewing the records of a child diagnosed with autistic spectrum disorder (ASD). Which of the following client outcomes should the nurse recognize as realistic for a client diagnosed with ASD?

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Naxlex Comprehensive Predictor Exams

A nurse in an emergency department is performing an assessment on a client who reports being sexually assaulted. Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

A nurse in a mental health facility is caring for a client who is upset about the loss of privileges due to repetitive negative behavior. Which of the following statements by the nurse demonstrates the effective use of assertive communication?

Correct Answer is D

Explanation

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