A nurse is planning care for an adolescent who has autism spectrum disorder. Which of the following outcomes should the nurse include in the plan of care?
Initiates social interactions with caregivers
Meets own needs without manipulating others
Changes behavior as a result of peer pressure
Acknowledges that his delusions are not real
The Correct Answer is A
A. Initiates social interactions with caregivers: One of the key goals for adolescents with autism spectrum disorder (ASD) is to improve social skills and interactions. Encouraging the adolescent to initiate social interactions is a positive and realistic outcome that promotes social development and enhances communication skills.
B. Meets own needs without manipulating others: While fostering independence and self-advocacy is important, adolescents with ASD may struggle with understanding social cues and may not manipulate others in a typical sense. This outcome may not be as relevant or achievable for the individual with ASD.
C. Changes behavior as a result of peer pressure: Adolescents with ASD may have difficulty understanding and responding to peer pressure in the same way as their neurotypical peers. This outcome may not be appropriate or realistic for someone with ASD, as it can lead to increased anxiety or discomfort.
D. Acknowledges that his delusions are not real: This outcome is more relevant to conditions such as schizophrenia or severe psychotic disorders, rather than ASD. Adolescents with autism may experience different cognitive challenges but generally do not have delusions in the way that individuals with psychotic disorders do.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "Don't worry about it. Your anxiety will lessen once the massage begins."
This response dismisses the client's concerns and may not be respectful of their boundaries. It does not acknowledge the client's discomfort and does not offer a solution to address their preference.
B. "Why don't you like to be touched by others?"
While the nurse is attempting to understand the client's feelings, this question might come across as invasive or judgmental. The client may not feel comfortable discussing their reasons for not liking to be touched, and this response does not offer an immediate solution to the issue at hand.
C. "I will request that the massage therapist wear gloves during your treatment."
This response shows an attempt to accommodate the client's preference by suggesting a practical solution, such as wearing gloves to create a physical barrier. However, it's important to note that some individuals may still find this uncomfortable, and it might not be a universally effective solution for everyone.
D. "I will tell your provider that you would like a treatment other than massage."
This response acknowledges the client's discomfort and demonstrates respect for their boundaries. It indicates the nurse's intention to advocate for the client's preferences and well-being. By informing the provider about the client's aversion to touch, the nurse opens the door to exploring alternative treatment options that are more suitable for the client's comfort level.
Correct Answer is A
Explanation
A. Hgb 10 g/dL
Anemia (low hemoglobin levels) is a common finding in individuals with anorexia nervosa due to inadequate nutrition, leading to a decreased production of red blood cells. Hemoglobin levels below the normal range are often seen in people with severe malnutrition, such as those with anorexia nervosa.
B. Blood glucose 100 mg/dL:
A blood glucose level of 100 mg/dL is within the normal range. Anorexia nervosa typically does not cause specific changes in blood glucose levels.
C. TIBC 11 mcg/dL:
Total Iron-Binding Capacity (TIBC) is a test that measures the blood's capacity to bind to iron. The given value of 11 mcg/dL is unusually low and might not be within the typical reference range. However, the significance of this value is not clear without the specific reference range for the laboratory performing the test.
D. Potassium 3.7 mEq/L:
A potassium level of 3.7 mEq/L is within the normal range. Electrolyte imbalances, including low potassium levels (hypokalemia), can occur in individuals with anorexia nervosa due to inadequate intake and purging behaviors. While this level is within the normal range, individuals with anorexia nervosa may still exhibit electrolyte imbalances that require monitoring and management.
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