Nokea
When providing care for the 3-year-old autistic child, which behavior is the nurse most likely to note?
- A. Constant use of the words 'I' and 'me'
- B. Insensitivity to pain
- C. Flexibility in normal routine
- D. Increased interest in others' actions
Correct Answer: B
Rationale: Insensitivity to pain is common in autism.
You may also like to solve these questions
If the unprescribed drug is an anabolic steroid, which other physical effect is common?
- A. Decreased lung capacity
- B. Bronzed skin
- C. Occurrence of or worsened acne
- D. Brittle nails
Correct Answer: C
Rationale: Acne is a common side effect of anabolic steroids.
If this diagnosis is accurate, it is most important for the nurse to assess for which characteristic finding?
- A. The mother is obsessed with the fear that her child will die.
- B. The mother is well versed in normal health patterns among children.
- C. The mother is responsible for creating the child's symptoms.
- D. The mother is overreacting to minor variations in her child's health.
Correct Answer: C
Rationale: Munchausen syndrome by proxy involves a caregiver causing or fabricating symptoms.
Which nursing action is most appropriate at this time?
- A. Postpone weighing the client until later.
- B. Confront the client about the water intake.
- C. Say nothing and weigh the client as usual.
- D. Subtract 2 lb (0.9 kg) from the client's weight.
Correct Answer: A
Rationale: Postponing weighing ensures accuracy and addresses manipulative behavior.
What advice is most appropriate to give the parents at this time?
- A. Tell the parents to disregard their son's behavior; it is normal grieving.
- B. Advise the parents to tell their son to snap out of it; his life is not over.
- C. Suggest transferring their son to another school.
- D. Advise the parents to ask their son about having thoughts of suicide.
Correct Answer: D
Rationale: Directly addressing suicidal thoughts is critical for safety.
Which nursing goal is the highest priority at this time?
- A. To improve the client's distorted body image
- B. To help the client use healthier coping techniques
- C. To restore normal nutrition and health
- D. To help the client develop assertiveness
Correct Answer: C
Rationale: Restoring nutrition is critical to address life-threatening malnutrition.