A 10-year-old child with Tourette?s disorder is receiving haloperidol as part of his treatment plan. When assessing the child at a follow-up visit, which statement by the child would lead the nurse to suspect that he is experiencing a side effect of the drug?
- A. Sometimes I feel like I?m so sleepy.
- B. I?m eating about the same amount as before.
- C. My muscles seem pretty flexible lately.
- D. I think I?m much more alert with this drug.
Correct Answer: A
Rationale: Haloperidol, an antipsychotic, commonly causes sedation as a side effect, so the child?s report of feeling sleepy (option A) suggests this. Option B (unchanged eating) and option C (flexible muscles) are not typical side effects. Option D (increased alertness) is opposite to haloperidol?s sedative effect.
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The nurse is counseling a family whose 4-year-old child has mild mental retardation. The nurse is working with the family on realistic long-term goals. Which of the following would be most appropriate?
- A. Locating suitable residential placement for the child
- B. Finding a foster home for the child
- C. Achieving independent functioning of the child as an adult
- D. Preventing the onset of psychiatric disorders in the child
Correct Answer: C
Rationale: For a child with mild mental retardation, realistic long-term goals focus on maximizing independence to the extent possible. Mild mental retardation typically allows individuals to achieve some level of independent functioning as adults, such as living in supported environments or performing simple jobs with guidance. Options A and B (residential placement or foster home) are premature and not necessarily appropriate for mild cases, as they imply more severe disability. Option D is less feasible, as psychiatric disorders may not be preventable due to the complexity of mental health conditions.
The nurse is preparing to initiate a behavioral treatment program for a child with encopresis. Which of the following would the nurse most likely implement first?
- A. Administration of mineral oil
- B. Bowel Cleansing
- C. Low-fiber diet
- D. Toilet sitting after each meal
Correct Answer: B
Rationale: For encopresis, the first step is typically bowel cleansing to address any fecal impaction, which can contribute to involuntary soiling. Mineral oil (option A) or toilet sitting (option D) may follow, and a low-fiber diet (option C) is counterproductive, as high fiber is preferred.
The nurse is giving a presentation comparing and contrasting autism disorder and Asperger syndrome. Which of the following would the nurse include as differentiating Asperger syndrome from autism disorder?
- A. Children typically do not engage in stereotypic behavior.
- B. They display age-appropriate intelligence.
- C. The children often reverse pronouns when speaking.
- D. They appear aloof and indifferent to others.
Correct Answer: B
Rationale: Asperger syndrome is distinguished from autism by the presence of age-appropriate intelligence and language development, though social challenges persist. Option A is incorrect, as stereotypic behaviors may still occur in Asperger?s. Option C is more typical of autism, not Asperger?s. Option D applies to both conditions and does not differentiate them.
The mother of a child with Asperger disorder tells the nurse that her child has few playmates. She states, 'He has such poor social skills with other children, and he strongly rejects any change in his routine by throwing a tantrum.' Based on this information, the nurse identifies which nursing diagnosis as the priority?
- A. Self-Care Deficits related to repeated tantrums
- B. Risk for Injury related to Asperger disorder
- C. Ineffective Family Coping related to having a child with Asperger disorder
- D. Risk for Social Isolation related to poor social skills of the child
Correct Answer: D
Rationale: The child?s poor social skills and resulting lack of playmates directly point to the nursing diagnosis of Risk for Social Isolation, as this is a primary concern based on the mother?s statement. Option A is less relevant, as tantrums do not directly relate to self-care deficits. Option B is not supported, as no immediate physical danger is described. Option C may apply but is less specific than social isolation in this context.
A nurse is assessing an 8-year-old girl with a mood disorder. Which of the following would the nurse most likely expect to assess?
- A. Statement from the child that she feels sad
- B. Behavioral problems
- C. Recurrent obsessions
- D. Ritualistic behavior
Correct Answer: A
Rationale: Mood disorders in children, such as depression, often present with verbalized feelings of sadness (option A). Behavioral problems (option B) may occur but are less specific. Options C and D are more characteristic of obsessive-compulsive disorder, not a mood disorder.
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