A nurse in an outpatient mental health facility is assessing a child who has autism spectrum disorder. Which of the following manifestations should the nurse expect?

Choice A rationale:

Telling the client, "It's not your choice to be here, so you have to accept the treatment we plan for you," disregards the client's autonomy and right to make decisions about their own healthcare. In mental health settings, respecting a patient's autonomy and involving them in the decision-making process is crucial for ethical care. This statement does not address the client's fear or provide any reassurance.

Choice B rationale:

Choice C rationale:

Asking, "Why do you think your provider will prescribe you medications that will make you sleep?" attempts to explore the client's fear, but it may come across as dismissive or invalidating. It could make the client feel unheard or misunderstood, which is not ideal in this situation.

Choice D rationale:

Stating, "I will make sure that we respect your right to refuse medications," is the most appropriate response. It acknowledges the client's fear and reassures them that their autonomy will be respected. It opens the door for a discussion about the client's concerns, allowing them to express their fears and preferences. Respecting the client's right to refuse medications is fundamental to ethical nursing practice and patient-centered care.

Choice A rationale:

Repositioning the NG tube is not the appropriate action for hyperosmolar dehydration. This condition occurs due to an excessive concentration of solutes in the body, leading to a decrease in intracellular water. Repositioning the tube would not address the hyperosmolarity issue.

Choice B rationale:

Increasing the rate of formula delivery may exacerbate the problem by introducing more concentrated formula into the client's system, worsening hyperosmolarity. This choice can lead to further dehydration and electrolyte imbalances.

Choice C rationale:

Adding water to the formula is the correct action in this scenario. Hyperosmolar dehydration requires dilution of the concentrated formula to reduce the osmolarity. By adding water to the formula, the nurse can decrease the concentration of solutes, helping to rehydrate the client effectively.

Choice D rationale:

Switching to a lactose-free formula is not the appropriate intervention for hyperosmolar dehydration. The issue lies in the concentration of the formula, not in its lactose content. Adding water is the more suitable and direct approach to address the problem.