A nurse is caring for a 4-year-old child who has autism spectrum disorder. Which of the following behaviors should the nurse expect?

Lack of eye contact.

Inability to play quietly.

Constant spinning of a toy.

Withdrawal from physical contact.

Repeated voicing in clothes.

Answer and Explanation

Correct Answer : A,C,D

A reason: Lack of eye contact. Children with autism spectrum disorder (ASD) often exhibit reduced or lack of eye contact, which can be a key indicator of social communication difficulties associated with ASD.

B reason: Inability to play quietly. While some children with autism might exhibit hyperactive behavior, an inability to play quietly is not a specific characteristic of ASD. It can be seen in various conditions, including attention deficit hyperactivity disorder (ADHD).

C reason: Constant spinning of a toy. Repetitive behaviors, such as spinning objects, are common in children with ASD. These behaviors provide sensory input and can be calming for the child.

D reason: Withdrawal from physical contact. Children with ASD often withdraw from physical contact due to sensory sensitivities. They might find certain touches uncomfortable or overwhelming.

E reason: Repeated voicing in clothes. Repeating phrases or sounds, known as echolalia, is common in ASD, but "repeated voicing in clothes" does not accurately describe this behavior. It seems like a typographical error.

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Correct Answer is ["B","C"]

Explanation

A reason: Hallucinations. Hallucinations can be distressing and are associated with various mental health conditions, but they are not a direct indicator of suicide risk without other contributing factors.

B reason: Depression. Depression is a significant risk factor for suicide. Clients experiencing persistent sadness, hopelessness, and a lack of interest in life are at a higher risk for attempting suicide.

C reason: Delusions. Delusions, particularly those that are paranoid or nihilistic, can contribute to feelings of hopelessness and despair, increasing the risk of suicide attempts.

D reason: Catatonia. Catatonia involves motor immobility and behavioral abnormality. While it is a serious condition requiring treatment, it is not a direct indicator of suicide risk without other contributing factors.

E reason: Tinnitus. Tinnitus, or ringing in the ears, is not associated with an increased risk of suicide. It is a physical symptom that does not directly influence suicidal behavior.

A. Provide additional attention to the client. B. Apply mechanical restraints before administering medication. C. Obtain a verbal contract from the client. D. Limit staff members who work with the client.

Correct Answer is C

Explanation

A reason: Provide additional attention to the client. While providing support and attention is important, it can reinforce attention-seeking behaviors in clients with borderline personality disorder. The care plan should balance support with boundaries.

B reason: Apply mechanical restraints before administering medication. Using restraints as a first-line intervention is not appropriate and should be avoided unless there is an immediate risk of harm. Less restrictive measures should be used initially.

C reason: Obtain a verbal contract from the client. A verbal contract, or a no-harm agreement, can be an effective strategy to engage the client in their own safety plan and reduce the risk of self-mutilation. It encourages the client to commit to seeking help before engaging in self-harm.

D reason: Limit staff members who work with the client. Consistency in care is important for clients with borderline personality disorder to build trust and maintain clear communication. Limiting staff changes helps provide stable and predictable care.

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A nurse is caring for a 4-year-old child who has autism spectrum disorder. Which of the following behaviors should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a history of suicide attempts. Which of the following findings places the client at risk for another suicide attempt?

Correct Answer is ["B","C"]

Explanation

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Correct Answer is C

Explanation

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