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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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A nurse is assessing a child who is suspected of having attention deficit hyperactivity disorder. Which of the following would the nurse identify as reflecting impulsiveness in the child?
- A. Inability to wait his turn
- B. Restlessness
- C. Difficulty completing a task
- D. Risk-taking behavior
Correct Answer: A
Rationale: Inability to wait one?s turn is a hallmark of impulsiveness in ADHD, as it reflects acting without forethought. Option B (restlessness) relates to hyperactivity, and option C (difficulty completing tasks) reflects inattention. Option D (risk-taking) may occur but is less specific to impulsiveness than waiting difficulties.
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.
The nurse is counseling a parent whose child has a communication disorder. Which of the following would the nurse emphasize when teaching the parent about this disorder?
- A. Providing the child with nonverbal activities
- B. Initiating conversations with the child frequently
- C. Stopping the child?s conversation if stuttering begins
- D. Asking the physician for medication to improve the child?s speech
Correct Answer: B
Rationale: Initiating frequent conversations encourages communication practice and skill development, which is key for managing communication disorders. Option A may be helpful but is less central than verbal interaction. Option C is counterproductive, as interrupting stuttering can increase anxiety. Option D is inappropriate, as medication is not typically indicated for communication disorders like stuttering.
A nurse is providing parent training for parents of a child diagnosed with a disruptive behavior disorder involving the use of time out. When describing how to implement this, which of the following would the nurse identify as the first step?
- A. Having the child recount the reason for the time out
- B. Clearly identifying what is required for the child
- C. Informing the child what will happen because of the behavior
- D. Placing the child in a designated area removed from others
Correct Answer: B
Rationale: The first step in implementing time out is to clearly identify the expected behavior (option B), as this sets the foundation for the child to understand what actions lead to consequences. Options A, C, and D follow later in the process.
The school nurse is caring for a 7-year-old child who has demonstrated a significantly lower-than-average score for mental age on standardized tests in reading. However, the child?s IQ scores were within the average range. The nurse interprets this information as suggesting which of the following?
- A. Communication disorder
- B. Attention deficit hyperactivity disorder
- C. Asperger syndrome
- D. Dyslexia
Correct Answer: D
Rationale: A significantly lower reading score despite an average IQ suggests dyslexia, a learning disorder affecting reading and language processing. Option A is too broad, as communication disorders encompass more than reading issues. Option B (ADHD) typically affects attention, not specifically reading. Option C (Asperger?s) is less likely, as it primarily involves social and behavioral challenges, not reading-specific deficits.