A nurse assesses a 3-year-old diagnosed with an autism spectrum disorder. Which finding is associated with the child disorder? The child
has occasional toileting accidents.
interrupts or intrudes on others.
cries when separated from a parent.
continuously rocks in place for 30 minutes.
The Correct Answer is D
A. Occasional toileting accidents may be developmentally normal at age 3 and are not specific to autism spectrum disorder (ASD).
B. Interrupting or intruding on others is more consistent with ADHD than autism.
C. Crying when separated from a parent is typical of separation anxiety, not autism.
D. Repetitive motor behaviors such as rocking, hand-flapping, or spinning are characteristic of autism spectrum disorder. These stereotypical movements are used for self-stimulation and regulation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. This statement is confrontational and asks why, which can escalate agitation rather than calm the patient.
B. This response is clear, firm, and sets limits on unsafe behavior while offering support. It reassures the patient that the nurse will maintain safety, but in a therapeutic, non-punitive way.
C. This is judgmental and blaming, which is not therapeutic and may increase hostility.
D. Threatening seclusion immediately without first trying therapeutic limit-setting escalates fear and aggression. Seclusion is a last resort after other interventions fail.
Correct Answer is B
Explanation
A. Culturally influenced responses relate to behaviors shaped by cultural norms, not a temporary feeling of restlessness before a test.
B. Mild anxiety is characterized by increased alertness, restlessness, and improved concentration, which can actually enhance performance on tasks like taking a test.
C. Displacement is a defense mechanism in which emotions are transferred to a less threatening object or person, not simply feeling restless.
D. Trait anxiety refers to a long-term personality characteristic of being generally anxious, not a situational response before an exam.
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