When the social worker, who has not had experience with autistic children, asks the nurse to identify signs and symptoms of the disorder, the nurse correctly identifies which finding as most characteristic?
- A. Repetitive body movements
- B. Intense parental attachment
- C. Early sexual development
- D. Profound mental retardation
Correct Answer: A
Rationale: Repetitive movements are a hallmark of autism.
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If ruminations about suicide are present, which observation by the nurse is most significant?
- A. The teen is not attending school regularly.
- B. The teen is hoarding sharp objects in the bedroom.
- C. The teen is not completing homework assignments.
- D. The teen is not participating in extracurricular activities.
Correct Answer: B
Rationale: Hoarding sharp objects indicates a high risk for self-harm.
What information is most helpful for the nurse to obtain next?
- A. The mother's expectations of an infant's behavior
- B. If the mother plans to finish high school
- C. The kinds of toys the mother has for the baby
- D. None of the above
Correct Answer: A
Rationale: Understanding the mother's expectations helps identify misconceptions contributing to the concern.
Which nursing goal is the highest priority at this time?
- A. To improve the client's distorted body image
- B. To help the client use healthier coping techniques
- C. To restore normal nutrition and health
- D. To help the client develop assertiveness
Correct Answer: C
Rationale: Restoring nutrition is critical to address life-threatening malnutrition.
Which of the following is the best indication that haloperidol (Haldol) is achieving a therapeutic effect?
- A. The client no longer hears voices.
- B. The client sleeps more than before.
- C. The client thinks of himself or herself as a good person.
- D. The client feels more energetic and rested.
Correct Answer: A
Rationale: Reduction in hallucinations indicates therapeutic efficacy.
Which response by the nurse provides the best explanation of the child's behavior?
- A. Thumb sucking is a primitive form of self-stimulation and security.
- B. Thumb sucking is a regressive behavior with a comforting effect.
- C. Thumb sucking substitutes for the missing fluids due to postoperative restriction of fluids.
- D. Thumb sucking satisfies the child's increased need for a familiar touch.
Correct Answer: B
Rationale: Thumb sucking is a regressive behavior triggered by stress, offering comfort.