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A nurse is planning care for a 3-year-old child who has autism spectrum disorder. Which of the following findings should the nurse expect?
- A. Readily initiates conversation
- B. Enjoys imaginative play
- C. Strong relationship with sibling and peers
- D. Attachment to objects that spin
Correct Answer: D
Rationale: The correct answer is D: Attachment to objects that spin. Children with autism spectrum disorder often exhibit repetitive behaviors, such as spinning objects, as a way to self-soothe or seek sensory stimulation. This behavior can serve as a coping mechanism and provide a sense of control for the child. Other choices are incorrect because children with autism spectrum disorder may have challenges in initiating conversations (A), engaging in imaginative play (B), or forming strong relationships with siblings and peers (C). By understanding the characteristics of autism spectrum disorder, the nurse can better tailor care and interventions to support the child's unique needs.
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A nurse is caring for a client who has post-traumatic stress disorder (PTSD). Which of the following interventions should the nurse include in the plan of care?
- A. Encourage the client to discuss past trauma
- B. Provide a structured routine
- C. Discourage emotional expression
- D. Limit social interactions
Correct Answer: B
Rationale: The correct answer is B: Provide a structured routine. Individuals with PTSD often benefit from a predictable routine as it provides a sense of safety and control. This intervention helps regulate emotions and reduces anxiety by creating a stable environment. Encouraging the client to discuss past trauma (A) may worsen symptoms if the client is not ready. Discouraging emotional expression (C) can be harmful as it may lead to emotional suppression. Limiting social interactions (D) may increase feelings of isolation and exacerbate symptoms. It's important to prioritize stability and structure in the plan of care for clients with PTSD.
A nurse is teaching about benztropine to a client who has schizophrenia. Which of the following statements should the nurse include in the teaching?
- A. This medication is given to help with extrapyramidal side effects
- B. This medication is given to help with your depression
- C. Benztropine helps alleviate your hallucinations
- D. Benztropine is used to counteract your tachycardia
Correct Answer: A
Rationale: Correct Answer: A: This medication is given to help with extrapyramidal side effects.
Rationale:
1. Benztropine is an anticholinergic medication commonly used to manage extrapyramidal side effects (EPS) caused by antipsychotic medications.
2. EPS include symptoms like tremors, muscle stiffness, and restlessness, which can occur with antipsychotic use.
3. By blocking certain neurotransmitters in the brain, benztropine helps alleviate these side effects.
4. Other choices are incorrect:
- B: Benztropine does not treat depression, as it is not an antidepressant.
- C: Benztropine does not directly address hallucinations, which are typically managed with antipsychotic medications.
- D: Benztropine does not specifically target tachycardia, which may be a side effect of other medications but not the primary indication for benztropine use.
A nurse is assessing a client who has generalized anxiety disorder. Which of the following findings should the nurse expect?
- A. Increased energy
- B. Restlessness
- C. Euphoric mood
- D. Depersonalization
Correct Answer: B
Rationale: The correct answer is B: Restlessness. In generalized anxiety disorder, individuals often experience restlessness due to persistent worry and fear. This can manifest as physical agitation and an inability to relax. Increased energy (A) is not typically associated with generalized anxiety disorder, as individuals may feel fatigued due to constant worrying. Euphoric mood (C) is more characteristic of conditions like bipolar disorder, not generalized anxiety disorder. Depersonalization (D) involves feeling detached from oneself and is more commonly associated with conditions like dissociative disorders, not generalized anxiety disorder.
A nurse is teaching the parent of a school-age child who has ADHD and a prescription for atomoxetine 40 mg daily. Which of the following information should the nurse include in the teaching?
- A. Expect the child to gain weight while taking this medication
- B. Crush the medication and mix it with 120 mL (4 oz) of juice
- C. Therapeutic effects will occur within 24 hr of starting treatment
- D. Administer the medication before the child goes to school in the morning
Correct Answer: D
Rationale: The correct answer is D: Administer the medication before the child goes to school in the morning. Atomoxetine is a non-stimulant medication used to treat ADHD. Administering it in the morning allows for optimal absorption and effectiveness during the school day. This helps in improving the child's focus and attention span in a learning environment. Additionally, taking the medication in the morning helps in minimizing potential side effects such as insomnia. Choices A, B, and C are incorrect because weight gain is not a common side effect of atomoxetine, crushing the medication can alter its effectiveness, and therapeutic effects usually take a few weeks to manifest, not within 24 hours.
A nurse is speaking with a client. Which of the following responses by the nurse demonstrates the communication technique of reflection?
- A. I would like to sit with you for a while
- B. You feel upset when this happens?
- C. Let’s work together to try to solve your problem
- D. Can you tell me what is happening now?
Correct Answer: B
Rationale: The correct answer is B because it demonstrates the communication technique of reflection. By saying "You feel upset when this happens?", the nurse is reflecting the client's feelings back to them, showing empathy and understanding. This technique helps the client feel heard and validated. Choice A is empathetic but does not reflect the client's feelings. Choice C focuses on problem-solving. Choice D is open-ended but does not reflect the client's emotions.