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A nurse is assessing a child who has autism spectrum disorder. Which of the following findings should the nurse expect?
- A. Delayed language development
- B. Spinning a toy repetitively
- C. Ritualistic behavior
- D. Consistent limit testing
Correct Answer: A, B, C
Rationale: Delayed language skills, repetitive behaviors, and a need for routines are common in autism spectrum disorder.
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A home-health nurse is assessing a client who has obsessive-compulsive disorder (OCD) and finds that the client demonstrates constant repetitive cleaning. The nurse knows that this behavior is an attempt to accomplish which of the following?
- A. Decrease anxiety
- B. Prevent aggressive and impulsive behaviors
- C. Manipulate others
- D. Decrease the time available for interaction with people
Correct Answer: A
Rationale: The correct answer is A: Decrease anxiety. The repetitive cleaning behavior in OCD is a manifestation of the client's attempt to reduce anxiety caused by intrusive thoughts or obsessions. This behavior provides temporary relief from anxiety by creating a sense of control. Choice B is incorrect because OCD cleaning behaviors are not primarily aimed at preventing aggressive or impulsive behaviors. Choice C is incorrect as the cleaning behavior is not typically a form of manipulation. Choice D is incorrect as the primary goal of the behavior is not to decrease interaction time but to manage anxiety.
A nurse on an inpatient eating disorders unit is caring for a client who has anorexia nervosa and has a body mass index of 17.2. Which of the following actions should the nurse take? (Select all that apply.)
- A. Provide the client with small meals frequently.
- B. Monitor the client's weight daily.
- C. Allow the client to choose the meals she will eat.
- D. Stay with the client during meals and for 1 hr afterward.
- E. Offer specific privileges for sustained weight gain.
Correct Answer: A, B, D, E
Rationale: The correct actions are A, B, D, and E.
A: Providing small meals frequently helps prevent overwhelming the client and supports gradual weight restoration.
B: Daily weight monitoring is crucial in tracking progress and ensuring the client's safety.
D: Staying with the client during meals and afterward helps prevent purging behaviors and offers support.
E: Offering privileges for sustained weight gain reinforces positive behavior and motivation for recovery.
Incorrect options:
C: Allowing the client to choose meals may lead to restrictive eating habits and hinder weight restoration.
F: No information given.
G: No information given.
A nurse who works in a psychiatric unit is caring for a client who has bipolar disorder. The client comes to the nurse's station at 0300 demanding that the nurse call the provider immediately. Which of the following responses by the nurse is appropriate?
- A. "You are being unreasonable, and I will not call your doctor at this hour."
- B. "I can't call a doctor in the middle of the night unless it's an emergency."
- C. "Go back to your room, and I'll try to get in touch with your doctor."
- D. "You must be very upset about something."
Correct Answer: D
Rationale: The correct answer is D: "You must be very upset about something." This response is appropriate because it acknowledges the client's emotions and demonstrates empathy. It shows the nurse's understanding of the client's distress, which is crucial in building a therapeutic relationship. By validating the client's feelings, the nurse can de-escalate the situation and gather more information to address the client's needs effectively.
Choice A is incorrect because it dismisses the client's request and can escalate the situation. Choice B is incorrect as it fails to acknowledge the client's emotions and lacks empathy. Choice C is incorrect as it does not address the client's emotional state and may lead to further agitation.
A nurse is caring for a client who has dementia. When performing a Mental Status Examination (MSE), the nurse should include which of the following data? (Select all that apply.)
- A. Ability to perform calculations
- B. Coping skills
- C. Recall ability
- D. Long-term memory
- E. Level of orientation
Correct Answer: A, C, D, E
Rationale: The correct answers are A, C, D, and E. In a Mental Status Examination for a client with dementia, assessing the ability to perform calculations (A) is important to evaluate cognitive function. Recall ability (C) is crucial as memory impairment is a common feature of dementia. Long-term memory (D) is essential to assess for signs of cognitive decline. The level of orientation (E) is vital to determine the client's awareness of time, place, and person, which can be impaired in dementia. Coping skills (B) are important but not typically assessed in an MSE for dementia. The other choices (F, G) do not directly relate to the cognitive impairment typically seen in dementia.
Which action is most therapeutic for a client with panic-level anxiety?
- A. Suggest the client rest in bed
- B. Remain with the client
- C. Medicate the client with a sedative
- D. Have the client join a therapy group
Correct Answer: B
Rationale: The correct answer is B: Remain with the client. This is the most therapeutic action because it provides immediate reassurance and support to the client, helping to reduce feelings of isolation and fear during a panic attack. By staying with the client, you can offer comfort and help them feel safe and supported.
Choice A is incorrect as suggesting the client rest in bed may not address their immediate needs during a panic attack. Choice C, medicating the client with a sedative, may provide short-term relief but does not address the underlying causes of the anxiety. Choice D, having the client join a therapy group, is not suitable during a panic attack as the client needs immediate support and intervention.