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.
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Related Questions
Correct Answer is C
Explanation
A. Respecting confidentiality is important, but the nurse has a legal and ethical duty to report child abuse, even if the patient discloses it in confidence.
B. Filing a report with the ethics committee does not fulfill the mandatory reporting requirement for child abuse.
C. The nurse must report suspected or disclosed child abuse to the appropriate child protection agency, even if the patient is now in rehabilitation. Anonymity may be used if allowed, but reporting is legally required.
D. Reassuring the patient about comfort in sharing does not address the immediate need to protect the child and fulfill mandatory reporting obligations.
Correct Answer is B
Explanation
A. While laboratory tests are important for assessing electrolyte imbalances and liver function, they are not the immediate priority in acute alcohol withdrawal.
B. Acute alcohol withdrawal can rapidly lead to seizures and delirium tremens, which are life-threatening. Patient safety and prevention of injury are the priority.
C. Neurological assessment is important, but first ensuring the client’s safety from potential seizures takes precedence.
D. IV access is necessary for fluid or medication administration, but it follows implementing immediate safety measures.
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