Chapter 26: Children and Adolescents

A child diagnosed with attention deficit hyperactivity disorder (ADHD) is going to begin medication therapy. The nurse should plan to teach the family about which classification of medications? a. Central nervous system stimulants b. Monoamine oxidase inhibitors (MAOIs) c. Antipsychotic medications d. Anxiolytic medications

ANS: A Central nervous system stimulants increase blood flow to the brain and have proven helpful in reducing hyperactivity in children and adolescents with ADHD. The other medication categories listed would not be appropriate.

Shortly after an adolescent's parents announce a plan to divorce, the teen stops participating in sports, sits alone at lunch, and avoids former friends. The adolescent says, "If my parents loved me, then they would work out their problems." What nursing diagnosis is most applicable? a. Ineffective coping b. Decisional conflict c. Chronic low self-esteem d. Disturbed personal identity

ANS: A Ineffective coping is evident in the adolescent's response to family stress and discord. Adolescents value peer interactions, and yet this child has eliminated that source of support. The distractors are not supported by the data in this scenario.

A parent diagnosed with schizophrenia and her 13-year-old child live in a homeless shelter. The child has formed a trusting relationship with a shelter volunteer. The child says, "My three friends and I got an A on our school science project." The nurse can assess that the child: a. displays resiliency. b. has a difficult temperament. c. is at risk for post-traumatic stress disorder. d. uses intellectualization to deal with problems.

ANS: A Resiliency enables a child to handle the stresses of a difficult childhood. Resilient children can adapt to changes in the environment, take advantage of nurturing relationships with adults other than parents, distance themselves from emotional chaos occurring within the family, learn, and use problem-solving skills.

Which assessment finding would cause the nurse to consider an 8-year-old child to be most at risk for the development of a psychiatric disorder? a. Being raised by a parent with chronic major depressive disorder b. Moving to three new homes over a 2-year period c. Not being promoted to the next grade d. Having an imaginary friend

ANS: A Statistics tell us that children raised by a depressed parent have a 30% to 50% chance of developing an emotional disorder. The chronicity of the parent's depression means it has been a consistent stressor. The other factors do not create ongoing stress.

A 12-year-old child has been the neighborhood bully for several years. The parents say, "We can't believe anything our child says." Recently, the child shot a dog with a pellet gun and set fire to a trash bin outside a store. The child's behaviors are most consistent with: a. conduct disorder (CD). b. defiance of authority. c. anxiety over separation from a parent. d. attention deficit hyperactivity disorder (ADHD).

ANS: A The behaviors mentioned are most consistent with the DSM-5 criteria for CD: aggression against people and animals; destruction of property; deceitfulness; rule violations; and impairment in social, academic, or occupational functioning. The behaviors are not consistent with ADHD and separation anxiety and are more pervasive than defiance of authority.

A 16-year-old adolescent diagnosed with conduct disorder (CD) has been in a residential program for three months. Which outcome should occur before discharge? a. The teen and parents create and consent to a behavioral contract with rules, rewards, and consequences. b. The teen completes an application to enter a military academy for continued structure and discipline. c. The teen is temporarily placed with a foster family until the parents complete a parenting skills class. d. The teen has an absence of anger and frustration for 1 week.

ANS: A The patient and the parents must agree on a behavioral contract that clearly outlines rules, expected behaviors, and consequences for misbehavior. It must also include rewards for following the rules. The patient will continue to experience anger and frustration. The patient and parents must continue with family therapy to work on boundary and communication issues. Separating the patient from the family to work on these issues is not necessary, and separation is detrimental to the healing process.

An adolescent is arrested for prostitution and assault on a parent. The adolescent says, "I hate my parents. They focus all their attention on my brother, who's perfect in their eyes." Which nursing diagnosis is most applicable? a. Ineffective impulse control, related to seeking parental attention as evidenced by acting out b. Disturbed personal identity, related to acting out as evidenced by prostitution c. Impaired parenting, related to showing preference for one child over another d. Hopelessness, related to feeling unloved by parents

ANS: A The patient demonstrates an inability to control impulses and problem solve by using adaptive behaviors to meet life's demands and roles. The defining characteristics are not present for the other nursing diagnoses. The patient has never mentioned hopelessness, low self-esteem, or disturbed personal identity.

An 11-year-old child, who has been diagnosed with oppositional defiant disorder (ODD), becomes angry over the rules at a residential treatment program and begins shouting at the nurse. Select the best method to defuse the situation. a. Assign the child to a short time-out. b. Administer an antipsychotic medication. c. Place the child in a therapeutic hold. d. Call a staff member to seclude the child.

ANS: A Time-out is a useful strategy for interrupting the angry expression of feelings and allows the child an opportunity to exert self-control. This method is the least restrictive alternative of those listed and should be tried before resorting to more restrictive measures.

When assessing a 2-year-old diagnosed with autism spectrum disorder, a nurse expects: a. hyperactivity and attention deficits. b. failure to develop interpersonal skills. c. history of disobedience and destructive acts. d. high levels of anxiety when separated from a parent.

ANS: B Autism spectrum disorder involves distortions in the development of social skills and language that include perception, motor movement, attention, and reality testing. Caretakers frequently mention the child's failure to develop interpersonal skills. The distractors are more relevant to ADHD, separation anxiety, and CD.

A child diagnosed with attention deficit hyperactivity disorder (ADHD) has hyperactivity, distractibility, and impaired play. The health care provider prescribed methylphenidate (Concerta). The desired behavior for which the nurse should monitor is: a. increased expressiveness in communicating with others. b. improved ability to participate in play with other children. c. ability to identify anxiety and implement self-control strategies. d. improved socialization skills with other children and authority figures.

ANS: B The goal is improvement in the child's hyperactivity, distractibility, and play. The incorrect options are more relevant for a child with a developmental or anxiety disorder.

A child blurts out answers to questions before the questions are complete, demonstrates an inability to take turns, and persistently interrupts and intrudes in the conversations of others. Assessment data show these behaviors relate primarily to: a. intelligence. b. impulsivity. c. inattention. d. defiance.

ANS: B These behaviors demonstrate impulsivity. Intelligence refers to measurements of one's cognitive ability. Inattention is a failure to listen. Defiance is willfully doing what an authority figure has said not to do.

What are the primary distinguishing factors between the behavior of children diagnosed with oppositional defiant disorder (ODD) and those diagnosed with conduct disorder (CD)? (Select all that apply.) The child diagnosed with: a. ODD relives traumatic events by acting them out. b. ODD tests limits and disobeys authority figures. c. ODD has difficulty separating from the parents. d. CD uses stereotypical or repetitive language. e. CD often violates the rights of others.

ANS: B, E Children with ODD are negativistic, disobedient, and defiant toward authority figures without seriously violating the basic rights of others, whereas children with CD frequently behave in ways that violate the rights of others and age-appropriate societal norms. Reliving traumatic events occurs with post-traumatic stress disorder. Stereotypical language behaviors are observed in autistic children. Separation problems with resultant anxiety occur with separation anxiety disorder.

A 15-year-old adolescent has run away from home six times. After the adolescent was arrested for prostitution, the parents told the court, "We can't manage our teenager." The adolescent is physically abusive to the mother and defiant with the father. The adolescent's problem is most consistent with criteria for: a. attention deficit hyperactivity disorder (ADHD). b. childhood depression. c. conduct disorder (CD). d. autism spectrum disorder (ASD).

ANS: C CDs are manifested by a persistent pattern of behavior in which the rights of others and age-appropriate societal norms are violated. The Diagnostic and Statistical Manual of Mental Disorders (5th edition) (DSM-5) identifies CDs as serious violations of rules. The patient's clinical manifestations do not coincide with the other disorders listed.

An adolescent was arrested for prostitution and assault on a parent. The adolescent says, "I hate my parents. They focus all their attention on my brother, who's perfect in their eyes." Which type of therapy might promote the greatest change in this adolescent's behavior? a. Bibliotherapy b. Play therapy c. Family therapy d. Art therapy

ANS: C Family therapy focuses on problematic family relationships and interactions. The patient has already identified problems within the family.

Which behavior indicates that the treatment plan for a child diagnosed with autism spectrum disorder was effective? The child: a. plays with one toy for 30 minutes. b. repeats words spoken by a parent. c. holds the parent's hand while walking. d. spins around and claps hands while walking.

ANS: C Holding the hand of another person suggests relatedness. Usually, a child with autism would resist holding someone's hand and stand or walk alone, perhaps flapping arms or moving in a stereotypical pattern. The other options reflect behaviors that are consistent with autistic disorder.

The child most likely to receive propranolol (Inderal) to control aggression, deliberate self-injury, and temper tantrums is one diagnosed with: a. attention deficit hyperactivity disorder (ADHD). b. post-traumatic stress disorder (PTSD). c. autism spectrum disorder (ASD). d. separation anxiety.

ANS: C Propranolol is useful for controlling aggression, deliberate self-injury, and temper tantrums of some children diagnosed with autism spectrum disorder. It is not indicated in any of the other disorders.

Shortly after a 15-year-old's parents announce a plan to divorce, the adolescent stops participating in sports, sits alone at lunch, and avoids former friends. The adolescent says, "All the other kids have families. If my parents loved me, then they would stay together." Which nursing intervention is most appropriate? a. Develop a plan for activities of daily living. b. Communicate disbelief relative to the adolescent's feelings. c. Assist the adolescent to differentiate reality from perceptions. d. Assess and document the adolescent's level of depression daily.

ANS: C The patient's perceptions that "all the other kids" are from two-parent households and that he or she is different are not based in reality. Assisting the patient to test the accuracy of the perceptions is helpful.

The parent of a child diagnosed with Tourette's disorder says to the nurse, "I think my child is faking the tics because they come and go." Which response by the nurse is accurate? a. "Perhaps your child was misdiagnosed." b. "Your observation indicates the medication is effective." c. "Tics often change frequency or severity. That does not mean they aren't real." d. "This finding is unexpected. How have you been administering your child's medication?"

ANS: C Tics are sudden, rapid, involuntary, repetitive movements or vocalizations characteristic of Tourette's disorder. They often fluctuate in frequency and severity and are reduced or absent during sleep.

When a 5-year-old child is disruptive, the nurse says, "You must take a time-out." The expectation is that the child will: a. go to a quiet room until called for the next meal. b. slowly count to 20 before returning to the group activity. c. sit on the edge of the activity until able to regain self-control. d. sit quietly on the lap of a staff member until able to apologize for the behavior.

ANS: C Time-out is designed so that staff can be consistent in their interventions. Time-out may require having the child sit on the periphery of an activity until he or she gains self-control and reviews the episode with a staff member. Time-out may not require having the child go to a designated room and does not involve special attention such as holding. Having the child count to 10 or 20 is not sufficient.

A nurse prepares the plan of care for a 15-year-old adolescent diagnosed with moderate intellectual developmental disorder (IDD). What are the highest outcomes that are realistic for this person? (Select all that apply.) Within 5 years, the person will: a. live unaided in an apartment. b. complete high school or earn a general equivalency diploma (GED). c. independently perform his or her own personal hygiene. d. obtain employment in a local sheltered workshop. e. correctly use public buses to travel in the community.

ANS: C, D, E Individuals with moderate intellectual developmental disorder progress academically to about a second grade level. These people can learn to travel in familiar areas and perform unskilled or semiskilled work. With supervision, they can function in the community, but independent living is not likely.

A parent diagnosed with schizophrenia and 13-year-old child live in a homeless shelter. The child has formed a trusting relationship with a volunteer. The teen says, "I have three good friends at school. We talk and sit together at lunch." What is the nurse's best suggestion to the treatment team? a. Suggest foster home placement. b. Seek assistance from an intimate partner violence program. c. Make referrals for existing and emerging developmental problems. d. Foster healthy characteristics and existing environmental supports.

ANS: D Because the teenager shows no evidence of poor mental health, the best action would be to foster existing healthy characteristics and environmental supports. No other option is necessary or appropriate under the current circumstances.

A 15-year-old adolescent is referred to a residential program after an arrest for theft and running away from home. At the program, the adolescent refuses to participate in scheduled activities and pushes a staff member, causing a fall. Which approach by the nursing staff would be most therapeutic? a. Neutrally permit refusals b. Coax to gain compliance c. Offer rewards in advance d. Establish firm limits

ANS: D Firm limits are necessary to ensure physical safety and emotional security. Limit setting will also protect other patients from the teenager's thoughtless or aggressive behavior. Permitting refusals to participate in the treatment plan, coaxing, and bargaining are strategies that do not help the patient learn to abide by rules or structure.

When group therapy is to be used as a treatment modality, the nurse should suggest placing a 9-year-old in a group that uses: a. play activities exclusively. b. group discussion exclusively. c. talk focused on a specific issue. d. play then talk about the play activity.

ANS: D Group therapy for young children takes the form of play. For elementary school children, therapy combines play and talk about the activity. For adolescents, group therapy involves more talking.

A 4-year-old child cries and screams from the time the parents leave the child at preschool until the child is picked up 4 hours later. The child is calm and relaxed when the parents are present. The parents ask, "What should we do?" What is the nurse's best recommendation? a. "Send a picture of yourself to school to keep with the child." b. "Arrange with the teacher to let the child call home at playtime." c. "Talk with the school about withdrawing the child until maturity increases." d. "Talk with your health care provider about a referral to a mental health professional."

ANS: D Separation anxiety disorder becomes apparent when the child is separated from the attachment figure. Often, the first time separation occurs is when the child goes to kindergarten or nursery school. Separation anxiety may be based on the child's fear that something will happen to the attachment figure. The child needs professional help.

Which child shows behaviors indicative of mental illness? a. 4-year-old who stuttered for 3 weeks after the birth of a sibling b. 9-month-old who does not eat vegetables and likes to be rocked c. 3-month-old who cries after feeding until burped and sucks a thumb d. 3-year-old who is mute, passive toward adults, and twirls while walking

ANS: D Symptoms consistent with an autistic spectrum disorder (ASD) are evident in the correct answer. The behaviors of the other children are within normal ranges.

A 5-year-old child moves and talks constantly, is easily distracted, and does not listen to the parents. The child awakens before the parents every morning. The child attended kindergarten, but the teacher could not handle the behavior. What is this child's most likely problem? a. Tic disorder b. Oppositional defiant disorder (ODD) c. Intellectual development disorder (IDD) d. Attention deficit hyperactivity disorder (ADHD)

ANS: D The excessive motion, distractibility, and excessive talkativeness suggest ADHD. Tic disorder is associated with stereotypical, rapid, and involuntary motor movements. Developmental delays would be observed if intellectual development disorder was present. ODD includes serious violations of the rights of others.

A 5-year-old child diagnosed with attention deficit hyperactivity disorder (ADHD) bounces out of a chair in the waiting room, runs across the room, and begins to slap another child. What is the nurse's best action? a. Call for emergency assistance from another staff member. b. Instruct the parents to take the child home immediately. c. Direct this child to stop, and then comfort the other child. d. Take the child into another room with toys to act out feelings.

ANS: D The use of play to express feelings is appropriate; the cognitive and language abilities of the child may require the acting out of feelings if verbal expression is limited. The incorrect options provide no outlet for feelings or opportunity to develop coping skills.