Ch. 23: Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence

15. A child diagnosed with severe autistic disorder has the nursing diagnosis of disturbed personal identity. Which outcome would best address this client's diagnosis? A. The client will name own body parts as separate from others by day 5. B. The client will establish a means of communicating personal needs by discharge. C. The client will initiate social interactions with caregivers by day 4. D. The client will not harm self or others by discharge.

ANS: A An appropriate outcome for this client is to name own body parts as separate from others. The nurse should assist the client in the recognition of separateness during self-care activities such as dressing and feeding. The long-term goal for disturbed personal identity is for the client to develop an ego identity.

6. An adolescent client who was diagnosed with conduct disorder at the age of 8 is sentenced to juvenile detention after bringing a gun to school. How should the nurse apply knowledge of conduct disorder to this client's situation? A. Childhood-onset conduct disorder is more severe than the adolescent-onset type, and these individuals likely develop antisocial personality disorder in adulthood. B. Childhood-onset conduct disorder is caused by a difficult temperament, and the child is likely to outgrow these behaviors by adulthood. C. Childhood-onset conduct disorder is diagnosed only when behaviors emerge before the age of 5, and therefore improvement is likely. D. Childhood-onset conduct disorder has no treatment or cure, and children diagnosed with this disorder are likely to develop progressive oppositional defiant disorder.

ANS: A The nurse should apply knowledge of conduct disorder to determine that childhood-onset conduct disorder is more severe than adolescent-onset type. These individuals are likely to develop antisocial personality disorder in adulthood. Individuals with this subtype are usually boys and frequently display physical aggression and have disturbed peer relationships.

13. When planning care for a client, which medication classification should a nurse recognize as effective in the treatment of Tourette's syndrome? A. Neuroleptic medications B. Antimanic medications C. Tricyclic antidepressant medications D. Monoamine oxidase inhibitor medications

ANS: A The nurse should recognize that neuroleptic (antipsychotic) medications are effective in the treatment of Tourette's syndrome. These medications are used to reduce the severity of tics and are most effective when combined with psychosocial therapy. Risperidone (Risperdal) has been shown to reduce symptoms by 21% to 61%.

5. After an adolescent diagnosed with attention deficit-hyperactivity disorder (ADHD) begins methylphenidate (Ritalin) therapy, a nurse notes that the adolescent loses 10 pounds in a 2-month period. What is the best explanation for this weight loss? A. The pharmacological action of Ritalin causes a decrease in appetite. B. Hyperactivity seen in ADHD causes increased caloric expenditure. C. Side effects of Ritalin cause nausea; therefore, caloric intake is decreased. D. Increased ability to concentrate allows the client to focus on activities rather than food.

ANS: A The pharmacological action of Ritalin causes a decrease in appetite that often leads to weight loss. Methylphenidate (Ritalin) is a central nervous symptom stimulant that serves to increase attention span, control hyperactive behaviors, and improve learning ability for clients diagnosed with ADHD.

16. A nursing instructor presents a case study in which a 3-year-old child is in constant motion and is unable to sit still during story time. The instructor asks a student to evaluate this child's behavior. Which student response indicates an appropriate evaluation of the situation? A. "This child's behavior must be evaluated according to developmental norms." B. "This child has symptoms of attention deficit hyperactivity disorder." C. "This child has symptoms of the early stages of autistic disorder." D. "This child's behavior indicates possible symptoms of oppositional defiant disorder."

ANS: A The student's evaluation of the situation is appropriate when indicating a need for the client to be evaluated according to developmental norms. The DSM-IV-TR indicates that emotional problems exist if the behavioral manifestations are not age-appropriate, deviate from cultural norms, or create deficits or impairments in adaptive functioning.

21. A nurse has taken report for the evening shift on an adolescent inpatient unit. Which client should the nurse address first? A. A client diagnosed with oppositional defiant disorder being sexually inappropriate with staff B. A client diagnosed with conduct disorder who is verbally abusing a peer in the milieu C. A client diagnosed with conduct disorder who is demanding special attention from staff D. A client diagnosed with attention deficit disorder who has a history of self-mutilation

ANS: B A client diagnosed with conduct disorder who is verbally abusing a peer in the milieu presents a potential safety concern that would need to be addressed by the nurse immediately.

22. A 6-year-old client is prescribed methylphenidate (Ritalin) for a diagnosis of attention deficit-hyperactivity disorder (ADHD). When teaching the parents about this medication, which nursing statement explains how Ritalin works? A. "Ritalin's sedation side effect assists children by decreasing their energy level." B. "How Ritalin works is unknown. It is a stimulant; however, it does combat the symptoms of ADHD." C. "Ritalin helps the child focus by decreasing the amount of dopamine in the basal ganglia and neuron synapse." D. "Ritalin decreases hyperactivity by increasing serotonin levels."

ANS: B It is unknown how Ritalin works, but even though it is a stimulant, it does decrease hyperactivity in individuals diagnosed with ADHD.

2. Which nursing intervention related to self-care would be most appropriate for a teenager diagnosed with moderate mental retardation? A. Meeting all of the client's self-care needs to avoid injury B. Providing simple directions and praising client's independent self-care efforts C. Avoiding interference with the client's self-care efforts in order to promote autonomy D. Encouraging family to meet the client's self-care needs to promote bonding

ANS: B Providing simple directions and praise is an appropriate intervention for a teenager diagnosed with moderate mental retardation. Individuals with moderate mental retardation can perform some activities independently and may be capable of academic skill to a second-grade level.

17. A client has an IQ of 47. Which nursing diagnosis best addresses a client problem associated with this degree of mental retardation? A. Risk for injury R/T self-mutilation B. Altered social interaction R/T nonadherence to social convention C. Altered verbal communication R/T delusional thinking D. Social isolation R/T severely decreased gross motor skills

ANS: B The appropriate nursing diagnosis associated with this degree of mental retardation is altered social interaction R/T nonadherence to social convention. A client with an IQ of 47 would be diagnosed with moderate mental retardation and may also experience some limitations in speech communications.

3. A child has been diagnosed with autistic disorder. The distraught mother cries out, "I'm such a terrible mother. What did I do to cause this?" Which nursing reply is most appropriate? A. "Researchers really don't know what causes autistic disorder, but the relationship between autistic disorder and fetal alcohol syndrome is being explored." B. "Poor parenting doesn't cause autistic disorder. Research has shown that abnormalities in brain structure and/or function are to blame. This is beyond your control." C. "Research has shown that the mother appears to play a greater role in the development of this disorder than the father." D. "Lack of early infant bonding with the mother has shown to be a cause of autistic disorder. Did you breastfeed or bottle-feed?"

ANS: B The most appropriate reply by the nurse is to explain to the parent that autism is believed to be caused by abnormalities in brain structure and/or function, not poor parenting. Autism occurs in approximately 6 per 1,000 children and is about four times more likely to occur in boys.

7. Which finding should a nurse expect when assessing a child diagnosed with separation anxiety disorder? A. The child has a history of antisocial behaviors. B. The child's mother is diagnosed with an anxiety disorder. C. The child previously had an extroverted temperament. D. The child's mother and father have an inconsistent parenting style.

ANS: B The nurse should expect to find a mother diagnosed with an anxiety disorder when assessing a child diagnosed with separation anxiety. Some parents instill anxiety in their children by being overprotective or by exaggerating dangers. Research studies speculate that there is a hereditary influence in the development of separation anxiety disorder.

8. A child has been recently diagnosed with mild mental retardation (MR). What information about this diagnosis should the nurse include when teaching the child's mother? A. Children with mild MR need constant supervision. B. Children with mild MR develop academic skills up to a sixth-grade level. C. Children with mild MR appear different from their peers. D. Children with mild MR have significant sensory-motor impairment.

ANS: B The nurse should inform the child's mother that children with mild MR develop academic skills up to a sixth-grade level. Individuals with mild MR are capable of independent living, capable of developing social skills, and have normal psychomotor skills.

18. A physician orders methylphenidate (Ritalin) for a child diagnosed with attention deficit-hyperactivity disorder (ADHD). Which information about this medication should the nurse provide to the parents? A. If one dose of Ritalin is missed, double the next dose. B. Administer Ritalin to the child after breakfast. C. Administer Ritalin to the child just prior to bedtime. D. A side effect of Ritalin is decreased ability to learn.

ANS: B The nurse should instruct the parents to administer Ritalin to the child after breakfast. Ritalin is a central nervous system stimulant and can cause decreased appetite. Central nervous system stimulants can also temporarily interrupt growth and development.

10. Which nursing intervention should be prioritized when caring for a child diagnosed with mild mental retardation? A. Encourage the parents to always prioritize the needs of the child. B. Modify the child's environment to promote independence and encourage impulse control. C. Delay extensive diagnostic studies until the child is developmentally mature. D. Provide one-on-one tutorial education in a private setting to decrease overstimulation.

ANS: B The nurse should prioritize modifying the child's environment to promote independence and encourage impulse control. This intervention is related to the nursing diagnosis self-care deficit. Positive reinforcement can serve to increase self-esteem and encourage repetition of behaviors.

11. A preschool child is admitted to a psychiatric unit with a diagnosis of autistic disorder. To help the child feel more secure on the unit, which intervention should a nurse include in this client's plan of care? A. Encourage and reward peer contact. B. Provide consistent caregivers. C. Provide a variety of safe daily activities. D. Maintain close physical contact throughout the day.

ANS: B The nurse should provide consistent caregivers as part of the plan of care for a child diagnosed with autistic disorder. Children diagnosed with autistic disorder have an inability to trust. Providing consistent caregivers allows the client to develop trust and a sense of security.

14. Which behavioral approach should a nurse utilize when caring for children diagnosed with disruptive behavior disorders? A. Involving parents in designing and implementing the treatment process B. Reinforcing positive actions to encourage repetition of desired behaviors C. Providing opportunities to learn appropriate peer interactions D. Administering psychotropic medications to improve quality of life

ANS: B The nurse should reinforce positive actions to encourage repetition of desired behaviors when caring for children diagnosed with disruptive behavior disorder. Behavior therapy is based on the concepts of classical conditioning and operant conditioning.

24. A child diagnosed with attention deficit-hyperactivity disorder (ADHD) is having difficulty completing homework assignments. What information should the nurse include when teaching the parents about task performance improvement? A. The parents should isolate the child when completing homework to improve focus. B. The parents should withhold privileges if homework is not completed within a 2-hour period. C. The parents should divide the homework task into smaller steps and provide an activity break. D. The parents should administer an extra dose of methylphenidate (Ritalin) prior to homework.

ANS: C By dividing the homework task into smaller steps, the child can remain more focused within a limited about of time. Physical activity can release pent-up energy that would distract from task completion.

12. A preschool child diagnosed with autistic disorder has been engaging in constant head-banging behavior. Which nursing intervention is appropriate? A. Place client in restraints until the aggression subsides. B. Sedate the client with neuroleptic medications. C. Hold client's head steady and apply a helmet. D. Distract the client with a variety of games and puzzles.

ANS: C The most appropriate intervention for head banging is to hold the client's head steady and apply a helmet. The helmet is the least restrictive intervention and will serve to protect the client's head from injury.

4. In planning care for a child diagnosed with autistic disorder, which would be a realistic client outcome? A. The client will communicate all needs verbally by discharge. B. The client will participate with peers in a team sport by day 4. C. The client will establish trust with at least one caregiver by day 5. D. The client will perform most self-care tasks independently.

ANS: C The most realistic client outcome for a child diagnosed with autistic disorder is for the client to establish trust with at least one caregiver. Trust should be evidenced by facial responsiveness and eye contact. This outcome relates to the nursing diagnosis impaired social interaction.

20. A mother questions the decreased effectiveness of methylphenidate (Ritalin), prescribed for her child's attention deficit-hyperactivity disorder (ADHD). Which nursing reply best addresses the mother's concern? A. "The physician will probably switch from Ritalin to a central nervous system stimulant." B. "The physician may prescribe an antihistamine with the Ritalin to improve effectiveness." C. "Your child has probably developed a tolerance to Ritalin and may need a higher dosage." D. "Your child has developed sensitivity to Ritalin and may be exhibiting an allergy."

ANS: C The nurse should explain to the mother that the child has probably developed a tolerance to Ritalin and may need a higher dosage. Methylphenidate (Ritalin) is a central nervous system stimulant in which tolerance can develop rapidly. Physical and psychological dependence can also occur.

19. Which should be the priority nursing intervention when caring for a child diagnosed with conduct disorder? A. Modify the environment to decrease stimulation and provide opportunities for quiet reflection. B. Convey unconditional acceptance and positive regard. C. Recognize escalating aggressive behaviors and intervene before violence occurs. D. Provide immediate positive feedback for appropriate behaviors.

ANS: C The priority nursing intervention when caring for a child diagnosed with conduct disorder should be to recognize escalating aggressive behaviors and to intervene before violence occurs. This intervention serves to keep the client and others safe. This is the priority nursing concern.

25. A nursing instructor is teaching about pharmacological treatments for attention deficit-hyperactivity disorder (ADHD). Which information about atomoxetine (Strattera) should be included in the lesson plan? A. Strattera, unlike methylphenidate (Ritalin), is a central nervous system depressant. B. When taking Strattera, a client should eliminate all red food coloring from the diet. C. Strattera will be a life-long intervention for clients diagnosed with this disorder. D. Strattera, unlike methylphenidate (Ritalin), is a selective norepinephrine reuptake inhibitor.

ANS: D Strattera is a selective norepinephrine reuptake inhibitor. Ritalin is classified as a stimulant. The exact mechanism by which these drugs produce a therapeutic effect in ADHD is unknown.

1. Which developmental characteristic should a nurse identify as typical of a client diagnosed with severe mental retardation? A. The client can perform some self-care activities independently. B. The client has advanced speech development. C. Other than possible coordination problems, the client's psychomotor skills are not affected. D. The client communicates wants and needs by "acting out" behaviors.

ANS: D The nurse should identify that a client diagnosed with severe mental retardation may communicate wants and needs by "acting out" behaviors. Severe mental retardation indicates an IQ between 20 and 34. Individuals diagnosed with severe mental retardation require complete supervision and have minimal verbal skills and poor psychomotor development.

9. A nursing instructor is teaching about the developmental characteristics of clients diagnosed with moderate mental retardation (MR). Which student statement indicates that further instruction is needed? A. "These clients can work in a sheltered workshop setting." B. "These clients can perform some personal care activities." C. "These clients may have difficulties relating to peers." D. "These clients can successfully complete elementary school."

ANS: D The nursing student needs further instruction about moderate mental retardation because individuals diagnosed with moderate MR are capable of academic skill up to only a second-grade level. Moderate MR reflects an IQ range of 35 to 49.

23. An 8-year-old client diagnosed with attention deficit-hyperactivity disorder (ADHD) was admitted 5 days ago for management of temper tantrums. What would be a priority nursing intervention during the termination phase of the nurse-client relationship? A. Set a contract with the client to limit acting-out behaviors while hospitalized. B. Teach the importance of taking fluoxetine (Prozac) consistently, even when feeling better. C. Discuss behaviors that are and are not acceptable on the unit. D. Ask the client to demonstrate learned coping skills without direction from the nurse.

ANS: D The priority nursing intervention during the termination phase of the nurse-client relationship should include encouraging the client to demonstrate the coping skills learning during the working phase of the nurse-client relationship.