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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.).

Delayed language development.

Consistent limit testing.

Spinning a toy repetitively.

Short attention span.

Ritualistic behavior.

Answer and Explanation

Correct Answer : A,C,E

The correct answers are: a. Delayed language development, c. Spinning a toy repetitively, and e. Ritualistic behavior.

Explanation:

Choice A Rationale: Delayed language development is a common characteristic of autism spectrum disorder (ASD). Children with ASD may exhibit difficulties in acquiring and using language appropriately, including delayed onset of speech, limited vocabulary, and challenges with syntax and pragmatics. This delay can significantly impact their ability to communicate effectively and engage in social interactions. Early intervention strategies, such as speech therapy and alternative communication methods, are often implemented to support language development in children with ASD.

Choice B Rationale: Consistent limit testing, characterized by challenging authority and testing boundaries, is not a hallmark feature of autism spectrum disorder (ASD). While some children with ASD may exhibit behaviors that appear oppositional or defiant, such behaviors are more commonly associated with other conditions such as oppositional defiant disorder (ODD) or conduct disorder (CD). ASD is primarily characterized by deficits in social communication and interaction, along with restricted, repetitive patterns of behavior, interests, or activities.

Choice C Rationale: Spinning a toy repetitively is a stereotypical behavior often observed in children with autism spectrum disorder (ASD). Repetitive behaviors, including spinning objects, rocking back and forth, or hand-flapping, are considered one of the core diagnostic criteria for ASD. These behaviors serve various functions for individuals with ASD, including sensory stimulation, self-soothing, or reducing anxiety. While repetitive behaviors can vary widely among individuals with ASD, they are a recognizable feature of the disorder.

Choice D Rationale: A short attention span is not a specific characteristic of autism spectrum disorder (ASD). While some children with ASD may exhibit difficulties with attention and focus, particularly in tasks that do not align with their specific interests or preferences, attention deficits are not universal among individuals with ASD. Additionally, attention difficulties are not considered a primary diagnostic criterion for ASD. Other neurodevelopmental disorders, such as attention-deficit/hyperactivity disorder (ADHD), are more commonly associated with impairments in attention and concentration.

Choice E Rationale: Ritualistic behavior, such as engaging in specific routines or repetitive actions, is a hallmark feature of autism spectrum disorder (ASD). Children with ASD often demonstrate a preference for predictability and sameness in their environment, leading to the development of rigid routines or rituals. These behaviors can serve as a source of comfort or security for individuals with ASD, providing structure and predictability in an otherwise unpredictable world. Ritualistic behaviors can manifest in various forms, such as insisting on following the same daily schedule, arranging objects in a specific order, or becoming distressed when routines are disrupted.

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Correct Answer is B

Explanation

Choice A rationale:

The statement "I know that men who are abusers gain power through intimidation." is accurate and aligned with the understanding of domestic violence dynamics. Abusers often use intimidation tactics to exert control over their victims, perpetuating a cycle of power and control.

Choice B rationale:

The statement "I have heard that abusers think of themselves as important and have high self-esteem." needs clarification. This statement is not entirely accurate. Abusers may display a façade of high self-esteem, but beneath it, they often have deep-seated insecurities. It's important to highlight that abusive behavior stems from a desire to control and dominate, rather than genuine self-worth.

Choice C rationale:

The statement "I know that abusers lack social supports and social skills." is inaccurate. Abusers can have social supports and social skills. Domestic violence is not solely determined by the lack of social skills or support; it is a complex issue rooted in power dynamics and learned behaviors.

Choice D rationale:

The statement "I have heard that abusers try to keep their partner isolated from others." is accurate and aligned with the understanding of domestic violence dynamics. Abusers frequently isolate their partners to maintain control over them, making it difficult for victims to seek help or support from others.

A. Plan a therapeutic diet for the client. B. Provide a structured environment for the client. C. Assess client's nutritional status. D. Request a mental health consult.

Correct Answer is C

Explanation

The correct answer is choice C.

Choice A rationale:

Planning a therapeutic diet is important for overall client care, but it might not be the first priority. The client's significant weight loss and distorted body image require more immediate attention to address potential underlying mental health concerns..

Choice B rationale:

Providing a structured environment is beneficial, but it might not be the first priority in this situation. The client's distorted perception of weight and significant weight loss necessitate more immediate assessment and intervention.

Choice C rationale:

Assessing the client's nutritional status is the first priority in this scenario. The client's weight loss of 11 kg (25 lb) over 3 months and belief that she is fat are indicators of a possible eating disorder. Nutritional assessment helps determine the severity of the issue and guides appropriate interventions.

Choice D rationale:

While requesting a mental health consult is important, it is not the first priority. Addressing the client's immediate physical health, which includes assessing her nutritional status and potential risk for complications related to her distorted body image, takes precedence.

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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.).

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Naxlex Comprehensive Predictor Exams

A home health nurse is speaking to a group of acute care nurses about domestic violence. Which of the following statements by one of the acute care nurses indicates a need for clarification by the home health nurse?

Correct Answer is B

Explanation

A nurse in the ER is admitting a client who has experienced a weight loss of 11 kg (25 lb) in the past 3 months. The client weighs 40 kg (88 lb) and believes she is fat. Which of the following aspects of care should the nurse consider the first priority for this client?

Correct Answer is C

Explanation

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