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 D

Explanation

Choice A rationale:

Existing conditions can indeed be a predisposing factor for stress. Chronic medical conditions, financial difficulties, or interpersonal conflicts can contribute to increased stress levels. These existing conditions create a foundation for stress to manifest.

Choice B rationale:

Heredity can also play a role in predisposing individuals to stress. Genetic factors can influence how a person responds to stressors and copes with challenging situations. A family history of anxiety disorders, for example, might increase an individual's susceptibility to stress.

Choice C rationale:

Learned responses are another predisposing factor for stress. If an individual has experienced traumatic events or has learned maladaptive coping mechanisms in response to stressors, they may be more prone to feeling stressed when faced with similar situations in the future.

Choice D rationale:

History of hypotension is the correct answer. Hypotension refers to abnormally low blood pressure. While it can have its own effects on the body, it is not typically considered a predisposing factor for stress. Stress is more closely associated with psychological and environmental factors rather than a person's blood pressure history.

A. "This is supposed to happen when you get old, right?” B. "Since his mother died, he has not been feeling well.” C. "My husband just didn't seem to know what he was doing. He has been forgetful for years.” D. "The changes in his behavior came on so quickly! I wasn't sure what was happening.”

Correct Answer is D

Explanation

Choice A rationale:

"This is supposed to happen when you get old, right?" is a common misconception but doesn't necessarily support the diagnosis of delirium. It could be attributed to normal aging changes.

Choice B rationale:

"Since his mother died, he has not been feeling well." indicates a potential stressor but doesn't directly address the rapid onset of behavioral changes, which is a hallmark of delirium.

Choice C rationale:

"My husband just didn't seem to know what he was doing. He has been forgetful for years." suggests a history of forgetfulness rather than an acute change in behavior, which is more indicative of chronic cognitive issues like dementia.

Choice D rationale:

(Correct) "The changes in his behavior came on so quickly! I wasn't sure what was happening." This statement supports the diagnosis of delirium, which is characterized by a sudden onset of confusion and changes in cognitive function. Delirium often develops rapidly, and the client's wife's observation aligns with this diagnostic criterion.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who is experiencing stress. The nurse recognizes which of the following is not a predisposing factor for stress?

Correct Answer is D

Explanation

A male client is admitted to the unit with a possible diagnosis of delirium. Which statement by the client's wife best supports the diagnosis?

Correct Answer is D

Explanation

Exhibit. The spouse of a male client with early-stage Alzheimer's disease (AD) tells the nurse, "I am just exhausted from the constant worry. I don't know what to do." Which action is best for the nurse to take next? (Select All That Apply.)

A nurse is caring for a client diagnosed with schizophrenia. The client states, "Did you know that I am engaged to the Prince of England?" The nurse should document that the client is experiencing which of the following types of delusions?

A nurse is caring for a client who lost all his possessions in a house fire and states, "I have no idea what I am going to do. I cannot think right now." Which of the following actions should the nurse take?

A nurse is caring for a child who has autism spectrum disorder. Which of the following findings should the nurse expect? (Select all that apply.).

A nurse on a mental health unit observes a diagnosed schizophrenic patient on antipsychotics having an impaired gait and uncontrollable tremors. The nurse should recognize that which of the following adverse effects may be occurring?

A nurse notices that a client who has moderate anxiety is pacing the corridor and rambling. As the nurse approaches, the client states, "I am at the end of my rope. I don't think I can take any more bad news." Which of the following responses should the nurse make?

A nurse on a mental health unit notices that a client is becoming increasingly agitated and throws a table when he is unable to select the television (TV) channel. Which of the following should be a priority action by the nurse?