Nokea
If and when the autistic child actually makes an effort to self-feed, which of the following suggestions is most appropriate for the nurse to make?
- A. Note if the self-feeding effort is repeated.
- B. Stop feeding the child thereafter.
- C. Demonstrate approval in some way.
- D. Offer food more frequently during the day.
Correct Answer: C
Rationale: Positive reinforcement encourages repetition of desired behaviors.
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Which statement regarding hospital admittance is most accurate?
- A. The client cannot be committed involuntarily unless the client is uncooperative at this time.
- B. The client cannot be committed involuntarily unless the client poses harm to self or others.
- C. The client cannot be committed involuntarily unless the client cancels office appointments.
- D. The client cannot be committed involuntarily unless the client refuses to take medications.
Correct Answer: B
Rationale: Involuntary commitment requires evidence of harm to self or others.
When the parents ask about the side effects of taking methylphenidate hydrochloride (Ritalin), the nurse correctly explains that the child may have which common cluster of signs and symptoms?
- A. Nausea, vomiting, and diarrhea
- B. Fatigue, drowsiness, and dry mouth
- C. Insomnia, tachycardia, and anorexia
- D. Hypotension, bradycardia, and constipation
Correct Answer: C
Rationale: Insomnia, tachycardia, and anorexia are common side effects of Ritalin.
When crisis intervention is provided, which nursing action takes priority?
- A. Explaining the benefits of professional counseling
- B. Encouraging the survivors to talk about the event
- C. Reassuring the survivors that they will adapt
- D. Advising consulting a physician for drug therapy
Correct Answer: B
Rationale: Talking about the event helps process trauma and is a priority in crisis intervention.
On the basis of the nurse's knowledge of autistic behavior, which nursing diagnosis is most likely to be a priority in the team conference?
- A. Ineffective health maintenance
- B. Chronic low self-esteem
- C. Risk for activity intolerance
- D. Risk for self-directed violence
Correct Answer: D
Rationale: Self-directed violence is a priority due to potential self-injurious behaviors.
It is normal for adolescents to test previously accepted values in order to acquire which attribute?
- A. Ideology
- B. Identity
- C. Intuition
- D. Insight
Correct Answer: B
Rationale: Adolescents seek to establish their identity, per Erikson's stages.