When assessing a 2-year-old child with suspected autism spectrum disorder, the nurse should be particularly alert for:

hyperactivity and attention deficits.

failure to develop interpersonal skills.

high levels of anxiety when separated from the mother.

a history of disobedience and destructive acts.

Answer and Explanation

The Correct Answer is B

B. Children with ASD may show reduced interest in social interactions, have difficulty understanding social cues, and may not engage in typical play with peers or caregivers. They might also exhibit challenges with nonverbal communication, such as making eye contact or using gestures.
A. While hyperactivity and attention deficits can be present in children with ASD, they are not as specific to the diagnosis as impaired social skills.
C. High levels of anxiety when separated from the mother could be seen in many conditions and are not particularly indicative of ASD.

D. A history of disobedience and destructive acts could be seen in many conditions and are not particularly indicative of ASD.

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Correct Answer is C

Explanation

C. Individuals with borderline personality disorder often struggle with intense emotions and may engage in self-harming behaviors as a maladaptive coping mechanism. Helping the client identify triggers for their distress and teaching them alternative coping strategies, such as mindfulness, grounding techniques, or distress tolerance skills, can empower them to manage their emotions in healthier ways.
A. Anxiolytic medications can help alleviate anxiety symptoms but they are not typically the first-line intervention for addressing acute distress in individuals with borderline personality disorder (BPD).
B. Restraint should not be the first response to a client expressing distress or suicidal ideation. Physical restraint should only be used as a last resort in situations where there is an imminent risk of harm to the client or others and should be implemented by trained professionals following established protocols.
D. Encouraging self-harm behaviors reinforces maladaptive coping strategies and can increase the risk of harm to the client. It is essential to provide support and interventions aimed at reducing self-harming behaviors.

A. father and mother have different parenting styles. B. history includes antisocial behavior. C. home environment lacks organization. D. mother was stressed during pregnancy.

Correct Answer is A

Explanation

A. Separation anxiety is primarily characterized by excessive distress or fear when separated from primary caregivers, and differences in parenting styles between the child's parents may affect the child's sense of security and exacerbate separation anxiety symptoms.
B. Separation anxiety is a common childhood anxiety disorder characterized by excessive worry or fear about separation from attachment figures, such as parents or caregivers. It is not typically associated with antisocial behavior
C. Separation anxiety is primarily related to the child's emotional response to separation from attachment figures and is not necessarily caused by environmental factors such as the organization of the home.

D. Prenatal stress may contribute to the child's overall risk for anxiety disorders. However, it is not a definitive predictor of separation anxiety in childhood.

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When assessing a 2-year-old child with suspected autism spectrum disorder, the nurse should be particularly alert for:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with borderline personality disorder reported to the nurse in the clinic that they feel empty and anxious and wants to cut their arms. The nurse should:

Correct Answer is C

Explanation

A nurse is caring for a 6-year old child suffering from separation anxiety. Which finding would a nurse expect when assessing the child? The child's:

Correct Answer is A

Explanation

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