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 A

Explanation

The correct answer is choice A: "Assess the client's need for assistance with ADLS."

Choice A rationale:

Safety is the top priority when caring for a client with major depressive disorder. Assessing the client's ability to perform Activities of Daily Living (ADLS) helps determine her level of functioning and any potential risks. Ensuring that the client can meet her basic self-care needs is essential for her well-being.

Choice B rationale:

Encouraging the client to create her own schedule of daily activities can be a valuable intervention, but it should come after addressing safety concerns. Choice A takes precedence as it directly relates to the client's immediate well-being.

Choice C rationale:

Teaching the client to use passive communication is not appropriate. Passive communication may hinder the client's ability to express her needs and advocate for herself. Assertive communication skills are more beneficial for her overall mental health.

Choice D rationale:

Isolating the client from unit activities may exacerbate her feelings of depression and loneliness. Encouraging engagement with appropriate unit activities and social interactions can contribute to her sense of belonging and aid in her recovery.

A. Sit with the client and offer simple, direct information. B. Explain the unit policies to the client and answer any questions he might have. C. Have the client attend group therapy immediately. D. Take the client on a tour of the unit and introduce him to all the staff members on duty.

Correct Answer is A

Explanation

Choice A rationale:

The nurse's approach of sitting with the client and offering simple, direct information is appropriate for a newly admitted client diagnosed with severe depression. This approach allows the nurse to establish a therapeutic rapport and provide the client with essential information in a clear and concise manner. People with severe depression often have difficulty processing complex information, so providing simple and direct information can enhance their understanding and alleviate any feelings of overwhelm.

Choice B rationale:

Explaining the unit policies and answering the client's questions might be overwhelming for someone with severe depression during their initial orientation. People experiencing depression often have difficulties with concentration and retaining information due to cognitive impairment. Presenting them with detailed policies and procedures might increase their anxiety and hinder their ability to absorb the information effectively.

Choice C rationale:

Having the client attend group therapy immediately might not be the best approach for someone with severe depression upon admission. Group therapy could be beneficial later in the treatment process, but initially, the client might not be emotionally ready to engage in group interactions. It's essential to establish a one-on-one therapeutic relationship and provide a stable environment before introducing them to group settings.

Choice D rationale:

Taking the client on a tour of the unit and introducing them to all the staff members on duty might be overwhelming and anxiety-inducing for someone with severe depression. It's crucial to approach the client with sensitivity and respect their emotional state. Introducing them to multiple staff members might increase their social anxiety and make them feel exposed, leading to further distress.

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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 is planning care for a client newly admitted with major depressive disorder. After ensuring safety, which of the following actions should the nurse plan to take?

Correct Answer is A

Explanation

A nurse is planning a unit orientation for a newly admitted client diagnosed with severe depression. Which of the following should be the nurse's approach?

Correct Answer is A

Explanation

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