Chapter 28: Nursing Care of the Child With an Alteration in Behavior, Cognition, or Development

The nurse is collecting data from the caregiver of an 8-year-old child who recently started soiling his underwear each day rather than using the toilet to defecate. This behavior indicates a symptom of:

Encopresis Encopresis is chronic involuntary fecal soiling beyond the age when control is expected (about 3 years of age).

The nurse is collecting data on an 18-month-old old child with a diagnosis of autism spectrum disorder (ASD). What clinical manifestation would likely have been noted in the child with this diagnosis?

The child does not make eye contact. Children with ASD often display hyperactivity, aggression, temper tantrums, or self-injury behaviors, such as head banging or hand biting. They may resist cuddling, lack eye contact, be indifferent to touch or affection, and have little change in facial expression. They do not develop a smiling response to others nor an interest in being touched or cuddled. In fact, they can react violently to attempts to hold them. They do not show the normal fear of separation from parents that most toddlers exhibit. Often they seem not to notice when family caregivers are present.

Many children with autistic spectrum disorder (ASD) are intellectually disabled.

True Many children with ASD are intellectually disabled, requiring lifelong supervision.

To feed lunch to a child with autism spectrum disorder (ASD), which action would it be most important for the nurse to take?

Use a repetitive series of movements. Children with ASD typically enjoy repetitive movements or the same action over and over.

The nurse is talking with the parents of a child who has been identified as having a learning disability. The parents state that there child performs well on oral examinations but struggles otherwise on exams. The nurse is aware that the parents are describing which disorder?

Dyslexia Children with dyslexia have difficulty with reading, writing, and spelling. Children with dyscalculia have problems with mathematics and computation. Children with dyspraxia have problems with manual dexterity and coordination. Children with dysgraphia have difficulty producing the written word.

Which sign is consistent with autism spectrum disorder (ASD) in a 2-year-old boy?

Performs repetitive activity with toys The repetitive behavior pattern with the toys, along with observation of communication and social impairment, would suggest ASD. Below-average intellectual function is a sign of intellectual disability. Loss of attained skills is a sign of Rett syndrome, which occurs only in girls. The presence of excellent language skills suggests Asperger syndrome.

The nurse is working with school-age children who are having enuresis or encopresis. What will most likely be the first step in this child's treatment?

The child will have a complete physical exam. The child with enuresis or encopresis may have a physiologic or psychological cause and may indicate a need for further exploration and treatment. A complete physical exam and assessment is done first to rule out any physical cause.

The nursing educator has completed an educational program for new nurses on eating disorders in teenagers. Which statement by a participant would indicate a need for further education?

"If they refuse to eat, we need to sit with them and not let them leave the table until they do eat something." Withdraw attention if the child refuses to eat: secondary gain is minimized if refusal to eat is ignored rather than with continuous attention. Mutually establish a contract related to treatment to promote the child's sense of control. Provide mealtime structure, as clear limits let the child know what the expectations are. Provide continuous supervision during the meal and for 30 minutes following it so that the child cannot conceal or dispose of food or induce vomiting.

An advance practice pediatric nurse practitioner (APPNP) is conducting a mental status examination with a 6-year-old girl. Which question would be most appropriate?

"Why does your pink doll hit all the other dolls?" The nurse is trying to elicit the fantasies and feelings underlying the child's play. Asking an open-ended question is likely to reveal this information. A 6-year-old might know the name of the president but the meaning is ambiguous. The other questions would elicit "yes" or "no" answers.

When can autistic behaviors first be noticed?

1 year of age Autistic behaviors may be first noticed in infancy as developmental delays or between the age of 12 and 36 months when the child regresses or loses previously acquired skills.

A 6-year-old is seen in a mental health clinic for possible hyperactivity. His mother reports that he is just "all boy." He has always been active and does not like to sit still for more than a minute. Which data would be most important to assess to help evaluate his behavior?

A review of the boy's typical day Evaluating whether children are hyperactive requires a careful history documenting attention span and activities.

The nurse is assessing a newborn and notes a low nasal bridge with short upturned nose, flattened midface, and a long philtrum with narrow upper lip. What does the nurse suspect to find in the mother's history?

Alcohol use These are typical facial features of a child with fetal alcohol syndrome from alcohol use of the mother while pregnant.

The therapy you would expect to see prescribed for an adolescent with anorexia nervosa would be:

Counseling to improve feelings of control over her body. Adolescents with eating disorders need to increase self-esteem or a feeling that they have control over their life.

You have been working with an adolescent with an eating disorder for several days. What is an indication that she is developing trust in you?

Her telling you that she is still inducing vomiting after each meal An adolescent has to be able to trust an adult before she can share confidences.

The nurse is admitting a 15-year-old female with severe weight loss from anorexia nervosa. She also has a fluid and electrolyte imbalance. The nurse is preparing the care plan. Which nursing diagnosis will be the highest priority?

Imbalanced nutrition, less than body requirements While any of the nursing diagnoses could apply to the situation, Imbalanced nutrition, less than body requirements would be the highest priority based on the criteria listed. The 5-year mortality rate for anorexia nervosa is 15% to 20% based on the physiological complications that occur.

The nurse is examining a child with fetal alcohol syndrome (FAS). Which assessment finding should the nurse expect?

Low nasal bridge with short upturned nose Typical FAS facial features include a low nasal bridge with short upturned nose, flattened midface, and a long philtrum with narrow upper lip. Microcephaly rather than macrocephaly is associated with FAS. Clubbing of fingers is associated with chronic hypoxia.

A mother is telling the school nurse about her concerns regarding her 13-year-old daughter, who is experiencing headaches. Her grades have dropped, and she is sleeping late and going to bed early every night. The nurse advises the mother that the first priority should be to:

Schedule an immediate history and physical examination. The first step is to conduct a physical examination to rule out or identify illnesses or physical problems that might cause depression. Once any physical causes have been ruled out, the health care team can determine the most appropriate approach to assess the girl's symptoms.

The nurse is doing a presentation on the diagnosis of anorexia nervosa to a group of pediatric nurses. Which clinical manifestations would the nurse teach this group to observe for in the adolescent with anorexia nervosa?

Soft and sparse body hair Persons with anorexia are visibly emaciated, with an almost skeleton-like appearance. They appear sexually immature, have dry skin and brittle nails, and often have soft, sparse body hair. Other symptoms include amenorrhea (absence of menstruation), constipation, hypothermia, bradycardia, low blood pressure, and anemia

Which is an example of impaired adaptive functioning in a 8/9-year-old girl/boy with a developmental disorder?

The child cannot properly dress his/herself. A child with impaired adaptive functioning would not be able to dress himself properly, if at all. The inability to copy a phone number or sentence or to read well reflects learning disorders.

Which sign or symptom suggests that a 5-year-old boy who does not maintain eye contact or speak may have autism spectrum disorder (ASD)?.

The child constantly opens and closes his hands/The child constantly pats his legs. Repetitive motor mannerisms such as constantly opening and closing the hands are a typical behavior pattern for ASD. A high level of activity and inattentiveness are typical symptoms of mental retardation. Decrease in head circumference suggests malnutrition or decelerating brain growth. A long face and prominent jaw are symptoms of fragile X syndrome

What finding would suggest that a 5-year-old boy might have a developmental disorder?

The child is not able to follow directions. A 5-year-old child should be able to follow simple directions. If he is unable to do this, he has not yet achieved a developmental milestone. Brushing his teeth with supervision and knowing cat and dog sounds are normal for this age. Having trouble with r, l, and y sounds is not unusual and may continue until age 7

The drug most commonly abused by children and adolescents is:

alcohol. Alcohol abuse occurs when a person ingests a quantity sufficient to cause intoxication. It is also the most commonly abused drug among children and adolescents.

The nurse is recording vital signs in the client diagnosed with complications of anorexia nervosa. Which findings are consistent with the condition?

• Weak pulse • Orthostatic hypotension • Hypothermia Anorexia nervosa is a condition most commonly seen in adolescents. In this condition the individual is obsessed with body weight. There is a noted loss of weight. The vital signs frequently display orthostatic hypotension, irregular and decreased pulse, or hypothermia

The nurse is assessing a 6-year-old with attention deficit/hyperactivity disorder (ADHD). The nurse observes the boy making repeated clicking noises and notes he has a slight grimace. The nurse recommends the boy receive further evaluation for:

Tourette syndrome. Repeated vocal tics such as sniffling, grunting, clicking, or word utterances are associated with Tourette syndrome. The syndrome consists of multiple motor tics and one or more motor tics occurring simultaneously at different times. ADHD and obsessive-compulsive disorder occur in 90% of children with Tourette syndrome. Vocal and motor tics are not typical indicators of Asperger syndrome, anxiety disorder, or autism spectrum disorder.

The nurse is observing a group of 2- and 3-year-olds in a play group. Which behavior noted in one of the children indicates to the nurse that the child may have autism spectrum disorder (ASD)?

While the other children are eating a snack, the child walks around the room feeling the walls and ignores the caregiver who offers him a snack. Children with ASD become completely absorbed in strange repetitive behaviors such as spinning an object, flipping an electrical switch on and off, or walking around the room feeling the walls. If these movements are interrupted or if objects in the environment are moved, a violent temper tantrum may result. These tantrums may include self-destructive acts such as hand biting and head banging. Although infants and toddlers normally are self-centered, ritualistic, and prone to displays of temper, autistic children show these characteristics to an extreme degree coupled with an almost total lack of response to other people

A group of students are reviewing the role of neurotransmitters in the development of depression. The students demonstrate a need for additional study when they identify which neurotransmitter as being involved?

γ-Aminobutyric acid (GABA) Both norepinephrine and dopamine play a role in mood. When alterations in the neurotransmission of norepinephrine and dopamine occur, the symptoms of depression (apathy, loss of interest and pleasure) result. Decreased levels of serotonin have also been implicated in depressive symptoms. GABA is associated with anxiety disorders

A 17-year-old child has been admitted with complications of anorexia nervosa. What diagnostic tests can be anticipated in the plan of care/treatment?

• Complete blood cell count • Metabolic panel Anorexia nervosa is characterized by dramatic weight loss as a result of decreased food intake and sharply increased physical exercise. Complications of anorexia include fluid and electrolyte imbalance, decreased blood volume, cardiac arrhythmia, esophagitis, rupture of the esophagus or stomach, tooth loss, and menstrual problems. A metabolic panel would highlight alterations in electrolyte status. Electrolyte imbalances are also associated with cardiac arrhythmia. Reduced dietary intake may result in anemia. This will be noted in the hemoglobin level. An alteration in blood volume will be reflected in the hematocrit level

Rumination disorder is a poorly understood condition of young children. This refers to:

Rechewing undigested food. Rumination is the rechewing of undigested food. It occurs primarily in infants

The nurse is caring for a 10-year-old girl with an anxiety disorder. During a physical examination, which physical finding would the nurse expect?

Patches of hair loss Patches of hair loss that occur with repetitive hair twisting or pulling are associated with anxiety. Watery, dilated eyes and the absence of nasal hair are often signs of substance abuse

The nurse on a pediatric mental health unit notices one of the clients continually avoids joining the other clients in the dining room for meals. The nurse is aware that the client is demonstrating characteristics of which disorder?

Social phobia Social phobia is a disorder characterized by the child or teen demonstrating a persistent fear of speaking or eating in front of others, using public restrooms, or speaking to authorities. Generalized anxiety disorder (GAD) is characterized by unrealistic concerns over past behavior, future events, and personal competence. Selective mutism refers to a persistent failure to speak. With separation anxiety the child may need to remain close to the parents, and the child's worries focus on separation themes.

A 10-year-old girl with ADHD has been on Ritalin (methylphenidate) for 6 months. The girl's mother calls and tells the nurse that the medication is ineffective and requests an immediate increase in the child's dosage. What should the nurse say?

"Let's set up an appointment as soon as possible." The nurse plays a vital role in administering medicines and observing and reporting responses. A face-to-face appointment with the family and the doctor or advance practice mental health nurse can help uncover client and parental factors that may be preventing success. Once it is established that the family is using the medication properly as well as instituting structure within the home, it can be determined if an increased dosage or alternate medicine would be appropriate. Deferring to the doctor will not elicit any information from the mother, and waiting will not address the current concerns. The teacher can only reveal partial information about the effectiveness of the medication, which can be reviewed once other factors have been addressed in a face-to-face visit with the family and client.

The mother of a 10-year-old boy with attention deficit hyperactivity disorder (ADHD) contacts the school nurse. She is upset because her son has been made to feel different by his peers because he has to visit the nurse's office for a lunch-time dose of medication. The boy is threatening to stop taking his medication. How should the nurse respond?

"You may want to talk to your physician about an extended-release medication." The nurse should encourage the family to explore with their physician the option of one of the newer extended-release or once-daily ADHD medications. The other statements are not helpful and do not address the mother's or boy's concerns.

The nurse is caring for a girl with anorexia who has been hospitalized with unstable vital signs and food refusal. The girl requires enteral nutrition. The nurse is alert for which complications that signal refeeding syndrome?

Cardiac arrhythmias, confusion, seizures The nurse should be aware that rapid nutritional replacement in the severely malnourished can lead to refeeding syndrome. Refeeding syndrome is characterized by cardiovascular, hematologic, and neurologic complications such as cardiac arrhythmias, confusion, and seizures. Orthostatic hypotension, hypertension, and irregular and decreased pulses are complications of anorexia but do not characterize refeeding syndrome.

A 7-year-old child is diagnosed with a learning disability involving reading, writing, and spelling. The nurse identifies this as:

Dyslexia. Dyslexia is a learning disability that involves reading, writing, and spelling. Dyscalculia is a learning disability that involves mathematics and computation. Dyspraxia is a learning disability that involves problems with manual dexterity and coordination. Dysgraphia is a learning disability that involves problems producing the written word.

The nurse is preparing a plan to educate the parents of a 10-year-old boy with a learning disorder. What will be part of this plan?

Explain the child's strengths and weaknesses. The nurse will explain the nature of the child's disorder but will also point out the strengths the child possesses as part of the plan. Encouraging parents to provide a personal space for the child is an intervention meant to promote autonomy and responsibility for a child with delayed growth and development. Regularly checking up on the child is a preventive measure to promote safety for a child with a developmental disorder. Learning facial expressions is important when a child has impaired communication skills.

The mother of an 8-year-old boy is concerned that her son has attention-deficit/hyperactivity disorder. She describes the symptoms he demonstrates. Which behavior should the nurse recognize as an example of impulsiveness?

Jumping out of his seat in the middle of class and running to the bathroom without the teacher's permission The disorder is characterized by three major behaviors: inattention, impulsiveness, and hyperactivity. Inattention makes children become easily distracted and often may not seem to listen or complete tasks effectively. Impulsiveness causes them to act before they think and therefore to have difficulty with such tasks as awaiting turns. With hyperactivity, children may shift excessively from one activity to another, exhibit excessive or exaggerated muscular activity, such as excessive climbing onto objects, constant fidgeting, or aimless or haphazard running. Repeating words or phrases spoken by others is echolalia and is associated with autistic spectrum disorder.

When teaching parents of a child with encopresis, what would you stress?

Not punishing the child for encopresis Encopresis (inappropriate soiling of stool) is a symptom of an underlying stress or disease. The child needs therapy to determine the cause.

A group of nursing students are reviewing the actions of various drugs used to treat mental health disorders in children. The students demonstrate understanding of the information when they identify which drug as potentiating the activity of serotonin in the brain?

Sertraline Sertraline is a selective serotonin reuptake inhibitor that potentiates serotonin activity in the brain. Trazodone is an atypical antidepressant that inhibits the reuptake of serotonin. Lithium influences the reuptake of serotonin and/or norepinephrine. Buspirone blocks the reuptake of dopamine

Steve, a 15-year-old Vietnamese boy, has been referred by his homeroom teacher to the school nurse for evaluation. The teacher is concerned that Steve may be suffering from major depression. Who should be the primary source of information to investigate the concerns about Steve?

Steve Steve is the primary historian, and the nurse should first elicit his perspective on the problem to establish a therapeutic alliance. The school nurse might have some input, but his or her contact with Steve may have been minimal. Steve's parents can provide insight and assistance, but they may not be willing to do so because of cultural differences. The teacher will provide a valuable timeline and observations as the individual who referred this case; however, Steve is still the primary historian.