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When the social worker, who has not had experience with autistic children, asks the nurse to identify signs and symptoms of the disorder, the nurse correctly identifies which finding as most characteristic?
- A. Repetitive body movements
- B. Intense parental attachment
- C. Early sexual development
- D. Profound mental retardation
Correct Answer: A
Rationale: Repetitive movements are a hallmark of autism.
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Which of the following information documented by the nurse provides the most evidence that the mother is bonding with her newborn with Down syndrome?
- A. The mother smiles and talks to the baby.
- B. The mother asks questions about infant care.
- C. The mother wants to see visitors who come.
- D. The mother feeds and burps the baby.
Correct Answer: A
Rationale: Smiling and talking to the baby indicate emotional engagement and attachment, key signs of bonding.
Which response by the nurse provides the best explanation of the child's behavior?
- A. Thumb sucking is a primitive form of self-stimulation and security.
- B. Thumb sucking is a regressive behavior with a comforting effect.
- C. Thumb sucking substitutes for the missing fluids due to postoperative restriction of fluids.
- D. Thumb sucking satisfies the child's increased need for a familiar touch.
Correct Answer: B
Rationale: Thumb sucking is a regressive behavior triggered by stress, offering comfort.
If ruminations about suicide are present, which observation by the nurse is most significant?
- A. The teen is not attending school regularly.
- B. The teen is hoarding sharp objects in the bedroom.
- C. The teen is not completing homework assignments.
- D. The teen is not participating in extracurricular activities.
Correct Answer: B
Rationale: Hoarding sharp objects indicates a high risk for self-harm.
When planning care for an autistic child, which nursing intervention is most appropriate?
- A. Providing interactive play activities
- B. Applying soft restraints while in bed
- C. Using a consistent caregiver
- D. Rocking the child as a calming technique
Correct Answer: C
Rationale: Consistency reduces anxiety in autistic children.
On the basis of the principles of crisis intervention, when is the best time for the nurse to offer assistance to those most affected by this incident?
- A. After the funeral
- B. Within 6 months
- C. Immediately
- D. Six weeks later
Correct Answer: C
Rationale: Immediate intervention addresses acute distress and prevents long-term issues.