The nurse is reviewing the records of a child diagnosed with autistic spectrum disorder (ASD). Which of the following client outcomes should the nurse recognize as realistic for a client diagnosed with ASD?

The client will establish trust with at least one caregiver by day 5.

The client will participate with peers in a team sport by day 4.

The client will communicate all needs verbally by discharge.

The client will perform most self-care tasks independently.

Answer and Explanation

The Correct Answer is D

Choice A rationale:

Establishing trust with a caregiver in just five days is a challenging and unrealistic expectation for a child diagnosed with autistic spectrum disorder (ASD). Building trust takes time, especially for individuals with ASD who may struggle with social interactions and forming connections.

Choice B rationale:

Participating in a team sport with peers by day 4 might be too ambitious for a child with ASD. Children with ASD often require gradual exposure and support to engage in social activities, and such rapid participation might lead to anxiety and discomfort.

Choice C rationale:

While communication goals are important for children with ASD, expecting them to communicate all needs verbally by discharge might not be realistic. Many children with ASD use alternative forms of communication, such as gestures or assistive devices, which should also be considered as valid modes of expression.

Choice D rationale:

The realistic outcome for a child diagnosed with ASD is that they will perform most self-care tasks independently. ASD often affects social and communication skills, but children can learn and develop the ability to manage self-care tasks with proper support and intervention. This outcome aligns with the developmental trajectory of children with ASD.

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Correct Answer is C

Explanation

The correct answer is Choice C.

Choice A rationale: Planning a therapeutic diet is essential for the client's recovery. However, it is not the first priority. Understanding the client's nutritional needs and current deficiencies should come before creating a diet plan.

Choice B rationale: Providing a structured environment is important to ensure the client follows the treatment plan and receives the appropriate support. However, it comes after assessing the client's current state and needs.

Choice C rationale: Assessing the client's nutritional status is the first priority because it provides critical information about the client's current health and guides all other aspects of care. Without knowing the client's nutritional status, it is challenging to make informed decisions about her treatment plan.

Choice D rationale: Requesting a mental health consult is important, especially given the client's belief that she is fat and the significant weight loss. However, before addressing her psychological needs, the nurse must understand her physical health status to provide comprehensive care.

A. "You are not responsible for your mother's stroke, but many people in your situation feel this way.” B. "Your mother will be fine. You shouldn't worry so much.” C. "Why do you blame yourself? You could not have prevented the stroke.” D. "So, it seems that you feel responsible for what happened to your mother.”

Correct Answer is D

Explanation

The correct answer is choiced. "So, it seems that you feel responsible for what happened to your mother.”

Choice A rationale:This response attempts to reassure the son but may come off as dismissive of his feelings. It does not encourage further discussion or exploration of his emotions.

Choice B rationale:This response is overly reassuring and dismisses the son’s feelings of guilt. It does not address his emotional state or encourage him to express his concerns.

Choice C rationale:This response questions the son’s feelings directly, which might make him defensive. It does not validate his emotions or encourage him to talk more about his feelings.

Choice D rationale:This response acknowledges the son’s feelings and encourages him to express his emotions. It is a therapeutic communication technique that helps the son feel heard and understood, which is crucial in providing emotional support.

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The nurse is reviewing the records of a child diagnosed with autistic spectrum disorder (ASD). Which of the following client outcomes should the nurse recognize as realistic for a client diagnosed with ASD?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

A nurse is caring for an older adult client diagnosed with a cerebrovascular accident and has right-sided paralysis and aphasia. The client's son tells the nurse it is his fault because he did not insist that his mother live with him. Which of the following responses should the nurse make?

Correct Answer is D

Explanation

A nurse on the medical unit is admitting a client with a history of alcohol use disorder. The nurse is aware that which of the following are potential physical symptoms of alcohol withdrawal? (Select all that apply.).

A nurse is caring for a client who has been diagnosed with end-stage liver cancer. The nurse recognizes that which of the following responses is an indication the client is in the denial phase of the grief process?

A nurse notices that a client who has moderate anxiety is pacing the corridor and rambling. As the nurse approaches, the client states, "I am at the end of my rope. I don't think I can take any more bad news." Which of the following responses should the nurse make?

A nurse is admitting a client who is about to undergo surgery for benign prostatic hypertrophy. The client states, "I don't know what I will do if they find that I have cancer." Which of the following should be the appropriate response by the nurse?

A nurse is assessing a client who is withdrawing from alcohol. Which of the following findings should the nurse expect? (Select all that apply).

A nurse is preparing to teach a client about the prescription of lithium (Eskalith) for the treatment of bipolar disorder. Which of the following statements should the nurse include in the teaching?