A nurse is caring for a client diagnosed with autism spectrum disorder (ASD). Which of the following assessment findings should the nurse recognize to be associated with ASD?
Echolalia
Ambivalence
Expressive affect
Associative looseness
The Correct Answer is A
A. Echolalia: Echolalia, the repetition of words or phrases spoken by others, is a common characteristic of autism spectrum disorder. It can be part of the individual’s attempt to communicate or self-stimulate and may be indicative of difficulties in expressive language development.
B. Ambivalence: Ambivalence, the state of having mixed feelings or contradictory ideas about something or someone, is more commonly associated with conditions like schizophrenia, not ASD.
C. Expressive affect: Individuals with ASD often have difficulties with expressive affect, meaning they may show limited emotional expression, which contrasts with the term "expressive affect" suggesting full emotional expression.
D. Associative looseness: Associative looseness, a symptom where a person’s thoughts are disconnected and fragmented, is more characteristic of schizophrenia than ASD.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. "I just don't remember what I did this morning." This statement reflects an inability to recall the events of the morning, which is a common symptom in Alzheimer's disease but does not constitute confabulation. It simply indicates memory loss.
B. "This morning, this morning, this morning..." Repetition of words or phrases can indicate a language or communication issue often seen in Alzheimer's disease but is not an example of confabulation. It may reflect confusion or perseverance.
C. "It was good. The Queen of England visited me there." Confabulation involves the creation of false memories or statements to fill in gaps in memory. The client's statement about the Queen of England visiting is a fabricated or distorted memory and is an example of confabulation. This choice is correct.
D. "Snip, snap. Take a nap." This phrase is nonsensical and may indicate disorganized thinking or speech, which can occur in Alzheimer's disease, but it is not an example of confabulation. It does not fill a memory gap with a fabricated story. Therefore, this choice is incorrect.
Correct Answer is B
Explanation
A. Ensuring that the client takes care of their ADLs to prevent dependence: While maintaining independence in activities of daily living (ADLs) is important, safety takes precedence because the client may not have the cognitive ability to perform ADLs safely.
B. Ensuring that the client environment is safe to prevent injury. Safety is the priority for clients with Alzheimer's disease due to their risk of confusion, disorientation, and falls. Creating a safe environment helps prevent accidents and injuries.
C. Ensuring that the client receives food they like to prevent anxiety: Providing familiar food can help reduce anxiety, but this is secondary to ensuring safety. The primary concern is to prevent injury in a client who may be disoriented or confused.
D. Ensuring that the client meets the other patients to prevent social isolation. While social interaction is beneficial, it is not the priority in the acute care setting for someone with Alzheimer's disease. The focus should first be on the client’s immediate safety and well-being.
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