Chapter 50: Behavior, Cognition, Development, or Mental Health/Cognitive or Mental Health Disorder

An adolescent comes to the school nurse and after being quiet for several minutes states, "I think the world will be better when I am gone." Which statement should be the nurse's first response to this adolescent?

"Have you made a plan to commit suicide?" Rationale: Health professionals involved with children and family caregivers must be aware of hints that signal an impending suicide attempt. Some young people will verbalize their hopelessness. It is important to address the safety needs of the adolescent first. This includes finding out if the adolescent has a plan to commit suicide. If a plan is in place, the person has given much thought to the process and intervention needs to happen. Asking about friendships and relationships do not address the immediate problem. Telling the child to see a counselor only pushes the child further away. Intervention should be made at the point the adolescent verbalizes suicide.

A 14-year-old girl is brought to the emergency department saying she was sexually assaulted. She tells the nurse that she feels guilty for having gone to a party where alcohol was being served. What is the nurse's best response?

"No one deserves to be raped, even going to a party with alcohol." Rationale: The girl needs reassurance that even though she made a poor decision going to the party, she still did not deserve to be raped. Chastising her for making a bad decision is only going to make her feel more guilty. It is better not to say, "I understand how you feel" unless the nurse has been in the same situation. It is not sincere or helpful.

A nurse is caring for a 10-year-old intellectually challenged girl hospitalized for a scheduled cholecystectomy. The girl expresses fear related to her hospitalization and unfamiliar surroundings. How should the nurse respond?

"Tell me about a typical day at home." Rationale: It is important to continue the usual routine of the hospitalized child, particularly of children with intellectual challenge. By asking an open-ended question about a typical day, the nurse can identify the routine activities that can potentially be duplicated in the hospital. Telling the girl she will be going home soon or asking about art supplies does not address her concerns. Asking whether she has talked to her parents is unhelpful at this time.

An adolescent was caught sneaking liquor out of the family liquor cabinet at home. When confronted by the parents, the adolescent admits to have been drinking daily for the last 3 years. When the parents talk to the health care provider about how to intervene for their child, what information would be appropriate to share with them?

Adolescents who have a family history of alcoholism may be more prone to problems with alcohol. Rationale: Adolescents who receive counseling and treatment for problem drinking are more likely to recover than those who have been problem drinkers for a long time. Experts know that alcoholism tendencies are hereditary for children with a family history of alcoholism. Adolescents are harder to treat because they feel like they are immortal and nothing can hurt them. Additionally, adolescents have a more rapid progression of the disease than adults. The earlier the alcohol problem is addressed, the more likely that person is to recover.

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

Not punishing the child for encopresis Rationale: Encopresis (inappropriate soiling of stool) is a symptom of an underlying stress or disease. It can be the manifestation of how the child expresses the trauma or depression that is occurring. The child needs therapy to determine the cause and to treat the problem. If a child is scolded or punished for encopresis or if more than normal attention is paid to the problem, the problem will worsen. Giving medications will not prevent the encopresis. The proximity of the bathroom will not impact the situation, because with encopresis the child soils the underwear and does not go to the bathroom.

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

The child is not able to follow directions. Rationale: 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.

In collecting data on a 7-year-old child with a possible diagnosis of school phobia, the nurse directs questions related to the following topics. Which would most likely be a cause of the child having school phobia?

The child may have a fear of being separated from the parent. Rationale: School-phobic children may have a strong attachment to one parent, usually the mother, and they fear separation from that parent, perhaps because of anxiety about losing her or him while away from home. Being a poor student and worrying about grades would be more common in the later school age and adolescence. A child may be anxious about language but that is generally not enough to cause phobias. If the child is bored at school the parents should ask to meet the teacher and define the child's needs. Many children need extra stimulation but that is not the same as having a phobia.

The nurse is working with school-aged 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. Rationale: 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.

Which behavior by a parent would lead the postpartum nurse to become concerned about the potential for abusive parenting

The mother does not choose to hold or feed her infant. Rationale: During the postpartum period, the nurse should be aware of parents who do not touch their infant within 24 hours and those who make disparaging remarks about the child's appearance, as this lack of contact could signal risk. However, not all parents immediately bond or react warmly to their newborns. Many may only tentatively touch or pick up their infant immediately. Observing a father sleeping soon after birth may just be a sign of fatigue after a long labor, not necessarily a sign of potential abuse. It is also very common for women to be weepy and nervous about being a parent, and it is the nurse's responsibility to help educate young parents on caring for their newborn. Having difficulty agreeing on a name for their newborn is fairly common if they have not discussed it in advance, but this does not mean they are potentially abusive.

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

Use a repetitive series of movements. Rationale: Children with an autism spectrum disorder have an array of symptoms. No two children may present with exactly the same ones. Many children on the spectrum spend many hours in the day in repetitive movement. If this is the case then repetitive movement would be the most beneficial way to feed the child. The child on the spectrum may be nonverbal, so allowing the child to ask questions is not a viable situation. Many of these children are hyperactive and they do not respond to authoritarian control. This form of control usually makes the situation worse. It would be very difficult to feed a child without the child seeing the utensil in front of the face.

A parent brings a preschooler to the behavioral clinic for evaluation. Upon entering the room, the child appears not to notice the nurse's presence. The child screams upon the nurse's touch. What condition should the nurse suspect?

autism spectrum disorder Rationale: Autistism spectrum disorder is characterized by markedly abnormal or impaired development in social interaction and communication. Social impairment is sustained and includes such things as poor eye contact, not liking to be touched, and preferring solitary activities. The findings are not indicative of Down syndrome or a learning disability. Down syndrome children are usually very friendly and like to be hugged and touched. A child with a learning disability does not have problems with socialization. These symptoms are not normal findings in preschoolers. Preschoolers are very interested in their surroundings and very interactive.

During adolescence, alcohol is connected to what problem frequently seen in this age group?

automobile accidents Rationale: Adolescents who drink and drive do not realize the impact of the alcohol in their reflexes and judgment. Fine motor control and judgment are affected even at lower levels of alcohol consumption. Driving is considered another adult behavior. There are no prying adult eyes on the adolescent drivers, so they think they are invincible and can drink and drive.

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

the student Rationale: The student is the primary historian, and the nurse should first elicit the student's perspective on the problem to establish a therapeutic alliance. The school nurse might have some input, but his or her contact with the student may have been minimal. The student'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, the student is still the primary historian.

The nurse suspects sexual maltreatment in a 10-year-old girl. The nurse would assess which primary finding to help make this determination?

vaginal discharge Rationale: An inspection of the external genitalia should be done at each yearly health assessment. An assessment for vaginal discharge or irritation should be done if the girl reports these problems or if sexual maltreatment is suspected. A vaginal discharge that suggests infection or a fourchette tear in a young girl may be an indication of sexual maltreatment. In the adolescent, these signs can be an indication of rape. The 10-year-old girl should be in Tanner stage 2. Decreased skin turgor would be an indication of dehydration, which may be related to a variety of reasons but not necessarily to sexual maltreatment.

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 Rationale: 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 9-year-old child with attention deficit hyperactivity disorder (ADHD) has been placed on the stimulant methylphenidate. The nurse knows that the teaching has been effective when the parents make which statement?

"Our child may have some side effects, like insomnia, headache, or stomach ache." Rationale: Insomnia, headache, and an upset stomach are common side effects of methylphenidate. The drug has a short half-life so the medication must be taken three times per day. The last dose should be right after school so as not to interfere with sleeping. Blood levels do not need to be drawn while on the medication. The medication starts working shortly after the person starts taking it, not 2 weeks later.

The nurse is assessing a child diagnosed with autism spectrum disorder (ASD). Which finding will the nurse expect to assess?

Indifferent attachment to a parent Rationale: A child with autism spectrum disorder can show a lack of or no attachment to parents. Motor skills are not expected to be slowed or delayed, because a child with ASD tends to spend hours in repetitive play and may display bizarre motor and stereotypic behavior. The child may 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. Frequently losing things can be associated with attention deficit hyperactivity disorder. Engaging in dangerous activities could be related to a conduct disorder.

A 9-year-old boy was in a car accident. The child is suffering from posttraumatic stress disorder. Which would be the best approach for treatment?

Individual psychotherapy sessions Rationale: Management of anxiety disorders consists of the use of medication at times but can also include cognitive behavioral therapy and individual, family, or group psychotherapy sessions. Psychostimulants would be used in ADHD. Antipsychotics help with children who have aggressive or repetitive behaviors. Sensory integration has been tried for the treatment of autism.

A child has been prescribed methylphenidate to take daily. Which nursing instructions are important to provide to the family?

Stress the need for adequate nutrition. Rationale: One of the side effects of methylphenidate is anorexia, so the nurse needs to instruct parents to monitor the child's weight and encourage adequate nutrition to prevent weight loss. Grapefruit does not affect methylphenidate, and methylphenidate does not cause dental problems. It also does not need to be kept in a dark container.

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

The child constantly pats his or her legs. Rationale: Repetitive motor mannerisms such as the child constantly patting his or her legs are a typical behavior pattern for autism spectrum disorder. Typical behavior for these children is repetitive activity. They demonstrate bizarre motor and stereotypic behaviors. A high level of activity and inattentiveness are typical symptoms of cognitive impairment. A decrease in head circumference suggests malnutrition or decelerating brain growth. A long face and prominent jaw are symptoms of Fragile X syndrome.

A nurse is working at a facility that provides care to children with developmental disabilities. Which role would be the nurse's most important?

advocate Rationale: Although the nurse would fulfill the roles of educator, care provider, and counselor, the nurse's most important role would be that of an advocate. Children with developmental disabilities often have special health needs. If so, they often interact with many different health care professionals (nurses, pediatricians, occupational therapists, physical therapists, psychologists, and speech and language pathologists) and may require adaptive modifications for school to maximize attendance and learning (e.g., assistance from health aides, nursing care, modifications for regular classes, special education classes, barrier-free facilities). A key nursing role is advocating to obtain services and care that will enable these children to fully participate in and benefit from their educational experiences.

A child with attention deficit hyperactivity disorder (ADHD) is prescribed methylphenidate hydrochloride. What should the nurse instruct the parents regarding an adverse effect of this medication?

Anorexia Rationale: An adverse effect of methylphenidate hydrochloride is anorexia. Sleepiness and garbled speech are not adverse effects of this medication. Children taking this medication can develop growth suppression and not accelerated growth in height.

The most common use disorder among children and adolescents is:

alcohol. Rationale: Alcohol misuse occurs when a person ingests a quantity sufficient to cause intoxication. It is also the most common substance use disorder among children and adolescents.

The nurse is caring for a child who has been hospitalized repeatedly at multiple hospitals. There is no clear medical diagnosis and the mother is threatening to leave the hospital against medical advice. The nurse suspects what issue?

caregiver-fabricated illness (formerly Munchausen syndrome by proxy) Rationale: Repeated hospitalizations that fail to produce a medical diagnosis, transfers to other hospitals, and discharges against medical advice are warning signs of caregiver-fabricated illness (formerly Munchausen syndrome by proxy).

Parents of a school-age child have begun a program of therapy that includes giving the child a token each time the child follows directions. Which theoretical framework provides the background for such a program?

behavioral theory Rationale: Reinforcing behaviors with rewards reflects a basic principle of behavioral therapy. This process reinforces the desired behaviors by replacing inappropriate behaviors with positive behaviors. Psychodynamic theory involves in-depth talk theory based on psychoanalysis. Systems theory is looking at all systems to see how they work together to produce a result. This work involves the study of the mind, body and spirit. A token economy allows for tokens to be accumulated for good behavior and then exchanged for a meaningful object or privilege.

An adolescent client has been diagnosed with bulimia nervosa. What does the nurse explain as the goal of treatment for this client?

restoring nutritional balance and a healthy self-image Rationale: Treatment focused on restoring nutritional balance and keeping a structured nutritional intake is key for bulimia nervosa. Cognitive behavior therapy concentrates on improving the person's distorted self-image, uncontrollable and excessive eating, and guilt and embarrassment associated with binging and purging.

A nursing student is learning about developmental disorders. The nursing instructor realizes that further instruction is necessary when the student makes which statement?

"A definitive cause can be found for every developmental disorder." Rationale: For most developmental disorders, causes cannot be identified. Families should not be blamed for causing developmental problems. After a thorough work-up and no identifiable cause is determined, the family should be helped to come to terms with the diagnosis. They should be helped to accept a child's delays and should work to facilitate the child's progress as the child grows and develops at his/her own pace and abilities.

The nurse is interviewing a 13-year-old girl with depression. During the course of the interview, the girl reveals that her best friend is thinking about committing suicide. Which response by the nurse would be most appropriate?

"Do you know how she is planning to kill herself?" Rationale: Because the girl is depressed, the nurse suspects that the girl is indirectly talking about herself, not her best friend. When an adolescent raises the issue of suicide, it is important to find out exactly how he or she is envisioning suicide and take measures to prevent an attempted suicide. Therefore, the nurse should ask how the "friend" is contemplating suicide in order gather this information and open a dialogue to encourage the girl to reveal she is talking about herself. Asking why, asking if the parents know, or asking if the girl is the only one who knows would not elicit the critical information about the method of suicide.

Parents of a 36-month-old child confide in the clinic nurse that their child does not speak and spends hours staring at their ceiling fan. They are worried that their child may have autism spectrum disorder. Which question would be important for the nurse to ask the parents?

"Does your child come and hug you or seek comfort from you?" Rationale: Children with autism spectrum disorder lack communication and social skills. These children often will not seek comfort, make eye contact, or develop peer relationships. It is important during the health history for the nurse to focus on the findings the parents are presenting and not on extra information that may or may not be helpful.

A nurse is discussing concerns about possible child abuse (child mistreatment) with the nursing supervisor. Which statement by the nurse requires correction by the supervisor?

"HIPAA prevents nurses from disclosing confidential information from parents." Rationale: The fact that the information was given in a confidential interview does not free a nurse from this responsibility (it is an exception under the confidentiality rules of the Health Insurance Portability and Accountability Act [HIPAA]) (Fraser, Matthews, Walsh, et al., 2010). Therefore, the nursing supervisor would need to correct this misinformation. The other comments are correct. All health care institutions and agencies have protocols on how the reporting of child abuse (child mistreatment) should be managed. It is important to learn the protocol required by your particular agency, community, and state. Nurses are included in the mandatory category in most states; this means they must report suspected child abuse (child mistreatment) when they identify it. Failure to do so can result in a fine, jail time, or loss of nursing licensure.

The parents of an adolescent are concerned about his mental health and have brought the adolescent into the physician's office for an evaluation. Which statements by the parents indicate that the child may have a mental health disorder? Select all that apply.

"He has started sleeping for only 3 hours each night." "He has lost 10 pounds over the last 4 months." "He used to be a straight-A student and now he's bringing home Cs and Ds." Rationale: Altered sleep patterns, weight loss, and problems at school are commonly found in children with mental health disorders. There also may be alterations in friendships and changes in extracurricular activity participation.

A nurse in a residential foster home is caring for a 17-year-old client with oppositional defiant disorder. The client is using profanity and refusing to complete assigned chores. The nurse reminds the client that there are only 5 minutes in which to finish the chores. The client throws a dirty plate at the wall. How should the nurse respond?

"I am sorry you are feeling so angry tonight but you must still complete your chores." Rationale: An adolescent with an oppositional defiant disorder can frequently demonstrate active defiance, has frequent anger and is noncompliant with adult requests or limits. In this situation the nurse's goal is to clearly but empathetically explain the rules and firmly adhere to them. Telling the adolescent there are only a few minutes to complete the chores does not exhibit empathy. Nor does the statement "I find your language offensive." It also does not address the rules. Letting the adolescent have a few extra minutes only reinforces the negative behavior and does not respect the rules of the facility.

The father of a 14-year-old daughter reports she has been rebelling at home. The use of a contract for behaviors has been discussed. Which response from the father indicates the need for further discussion?

"I can relax rules at home if she has had a bad day." Rationale: When dealing with a child who is having behavioral issues it is important for the parents to be consistent. Once rules and expectations are established the parents need to remain consistent. When a child is angry arguments should be avoided. The parents need to address the child in clear and calm tones.

An extremely thin preadolescent is being assessed by the nurse. Which client statement will cause the nurse to suspect the client is experiencing anorexia nervosa?

"I feel chubby no matter what I wear." Rationale: Characteristics of a client with anorexia nervosa include a severely distorted body image with an intense fear of gaining weight or becoming fat. The goal to be a model is not consistent with that of anorexia nervosa. Enjoying fashion is not a characteristic of anorexia nervosa. The fear of food being poisoned is a characteristic of paranoid behavior.

The nurse is speaking to a parent of a child diagnosed with an autism spectrum disorder. The parent states, "There are medications out there for everything. I cannot believe there is not a medication to help cure my child." What is the best response by the nurse?

"I know you must be frustrated about trying to get the best help for your child. Although there is not a medication to help treat autism spectrum disorders, with various therapies your child can function to the best of one's abilities." Rationale: Therapeutic communication is needed to establish a therapeutic relationship with clients and their families. Acknowledging the parent's frustration and then discussing potential interventions is the best statement choice. Deflecting the statement about medications to the health care provider is a non-therapeutic statement. Telling the parent to shift one's focus is also non-therapeutic. Stating that autism-based behaviors can be controlled with diet and therapy is an untrue statement.

A 10-year-old girl with attention deficit hyperactivity disorder (ADHD) has been on 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. Which response by the nurse would be most appropriate?

"Let's set up an appointment for you to come in as soon as possible. Rationale: The nurse plays a vital role in administering medicines and observing and reporting responses. A face-to-face appointment with the family and the primary health care provider or advanced practice mental health nurse can help uncover patient 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.

While interviewing an adolescent client with depression, the client reveals to the nurse that he has considered hurting himself. Which response by the nurse would be most appropriate?

"Tell me exactly how you would hurt yourself." Rationale: It is important to find out exactly how the adolescent is envisioning harming himself and to take measures to prevent an attempted suicide. Asking the adolescent why, if his parents know, or if he has discussed this with anyone else would elicit little information about the adolescent's thoughts.

The parents of an 18-month-old toddler are concerned that their toddler no longer makes eye contact, does not respond to their smiles or other facial expressions, does not point to toys, and no longer speaks. They said that their toddler used to be able to say "mama" or "dada." The parents started noticing these changes in behavior 3 months ago. Which information can be provided to the parents?

"There are many behaviors that can be thought of as signs of autism spectrum disorders, but only a health care provider can confirm the diagnosis." Rationale: The nurse will respond by providing current facts, which in this case is that only a health care provider can confirm a diagnosis of an autism spectrum disorder. Autism spectrum disorders are not diseases that are curable but a spectrum of disorders that affect cognitive, speech, and social interaction. Autism spectrum disorders range from mild to severe as do the behaviors. Autistic behaviors may be first noticed in infancy as developmental delays or between the age of 12 and 36 months when the toddler regresses or loses previously acquired skills. Although infants and toddlers on the autism spectrum may have difficulty establishing or maintaining eye contact, those who are not able to establish eye contact or have difficulties establishing eye contact need to be first tested for vision and hearing to rule out eye or hearing defects. It is inappropriate for the nurse to state, "when your toddler begins to speak, a determination is easier." The toddler was already speaking and stopped speaking 3 months before the visit to the health care provider.

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 lunchtime 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." Rationale: 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.

A nurse is providing care to an adolescent being treated for anorexia as an outpatient. The nurse is evaluating the adolescent's weight gain over the past week. The nurse determines that the adolescent is achieving the expected outcome when the adolescent shows a gain of how much for the week?

0.5 to 1 lb (0.27 to 0.45 kg) Rationale: A weight gain of 2 to 3 lb/week (0.91 to 1.37 kg/week) while hospitalized, and 0.5 to 1 lb/week (0.27 to 0.45 kg/week) in outpatient programs, is targeted for clients undergoing treatment for anorexia.

A family includes a 9-year-old child. The nurse suspects that the family has caregiver-fabricated illness (formerly Munchausen syndrome by proxy). Which nursing intervention is best when assessing the child and family in the pediatrician's office?

Ask to speak to the child separate from the family. Rationale: In caregiver-fabricated illness (formerly Munchausen syndrome by proxy), parents report prolonged, unexplained illnesses for the child. Even though the child has been seen for medical treatment, the health issues are never resolved. The parent shows a lack of concern about the symptoms and the illnesses. Symptoms usually occur when no one else is present. The nurse should speak to the child alone, video and document interactions, contact the medical team, and contact protection services for the child if needed.

An 11-year-old client has come to the school nurse more than 15 times for somatic complaints during the first quarter of school and has subsequently left school after each visit. What should the school nurse do?

Contact the child's parents to discuss the situation. Rationale: The best approach is to involve the child and the parent. Contact with the parents can elicit additional information and provide family details that may be contributing to the child's school refusal. A home visit might make the family take a defensive stance. The teacher's information will supplement the details provided by the parents. The nurse should quickly address the signs of school refusal; waiting would not benefit the child.

An adolescent has been diagnosed with bulimia, and the parents are asking how to best deal with this problem. What suggestion should the nurse make to the parents to help care for the adolescent?

Develop a contract with the adolescent, setting goals of behavior and her diet, as well as privileges gained by meeting the contracted goals. Rationale: Developing a contract with the adolescent, as part of a behavior modification program, lays out clearly defined behaviors and the child's responsibilities related to bulimia and its management. Parents need to be aware and report any verbalizations about being overweight or altered body image. Antiemetics are not appropriate for this disorder since there is not nausea associated with it and it is impossible to monitor the adolescent continually.

The nurse is caring for a 13-year-old girl with a nursing diagnosis of "Ineffective coping related to inability to deal with life stressors as evidenced by few or no meaningful friendships and low self-esteem." Which intervention would be the priority to promote coping skills?

Encourage her to discuss her thoughts and feelings. Rationale: The priority intervention is to encourage her to discuss her thoughts and feelings, as this is an initial step toward learning to deal with them appropriately. The other interventions are appropriate, but the priority intervention is to encourage discussion and obtain information from the child. This way the nurse can develop and refine the interventions based on the child's thoughts and feelings.

The school nurse is assessing a 12-year-old client suspected of having bulimia. Which assessment finding would the nurse expect to see?

Eroded dental enamel Rationale: Bulimia is an eating disorder that causes the child to eat and then vomit purposely. Teens with this disorder may also use laxatives, diuretics, and purgative aids. These habits lead to severe erosion of the teeth because the teeth are constantly exposed to gastrointestinal juices. The other findings are more consistent with anorexia.

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. Rationale: 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 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 Rationale: 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 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 Rationale: 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 and exhibit excessive or exaggerated muscular activity (e.g., 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.

The adolescent client has become bored with the video game system, which had been the positive reward for cleaning one's room. Which intervention would be most effective intervention at this time?

Let the adolescent choose another reward that would be more fun. Rationale: Positive rewards need to be viewed as desirable to motivate desired behavior changes. One method of rewards/punishment is the token system. The child is rewarded for good behavior with a token and the token is taken away for inappropriate behavior. When the child has collected a specified amount of tokens or a specific time has occurred the token can be exchanged for a reward. If the adolescent is bored or distracted with the video game then it is not serving the purpose for which it was intended. The nurse should allow the adolescent to select another reward as a result of good behavior and as specified by the parents in the rules for the adolescent. Making the adolescent continue to use the gaming system only increases anger, frustration and aggression.

A nurse is caring for a 17-year-old female client with bulimia. Which complication of this disease may the nurse see in this child?

Menstrual problems Rationale: Paralysis, hernia, and acne are not distinguishing features of bulimia. Bulimia is an eating disorder that has assessment findings of menstrual problems, esophagitis, cardiac arrhythmias, and fluid and electrolyte imbalance.

With all the warnings on cigarette packages and media coverage of the side effects of tobacco use, why do school-age children and adolescents continue to smoke or chew tobacco?

School-age and adolescent children view the threats to their health as far in the future, and the child feels that he or she can stop at any time. Rationale: Children who smoke or use tobacco cannot conceive of the future effects that tobacco will have on their bodies. They see others smoking around them and, through example, think smoking is OK for them. They do not understand the effect on their long-term health because they are focused on the here and now.

A nurse is assessing a little boy who has been diagnosed with Tourette syndrome. Which finding would the nurse expect to see?

Speaks sudden, fast phrases out of context Rationale: In Tourette syndrome, children have uncontrolled vocal tics. Toe walking and hand flapping/spinning is seen more in children with autism spectrum disorder. Lack of eye contact can also be found in children with autism spectrum disorder, but also can be normal in kids.

What is an example of impaired adaptive functioning in an 8-year-old girl with a developmental disorder?

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

The nurse is conducting an assessment of a 5-year-old client. During the assessment, the nurse notes that the child does not maintain eye contact or speak. The nurse suspects an autism spectrum disorder. Which additional finding would help support the nurse's suspicion?

The child constantly opens and closes the hands. Rationale: Repetitive motor mannerisms such as constantly opening and closing the hands are a typical behavior pattern for autism spectrum disorder. A high level of activity and inattentiveness are typical symptoms of intellectual disability. Decrease in head circumference suggests malnutrition or decelerating brain growth. A long face and prominent jaw are symptoms of fragile X syndrome.

The nurse is concerned that a child is the victim of caregiver-fabricated illness (formerly Munchausen syndrome by proxy). Which assessment finding supports this concern? Select all that apply.

The child's symptoms are vague and only reported by the parent. The mother stays with the child continuously and provides care. The family makes repeated visits to the health care facility the when child is well. The mother is a student nurse and is under a great deal of stress. Rationale: Two classic findings of caregiver-fabricated illness (formerly Munchausen syndrome by proxy) are usually present: first, the symptoms are not easily detected by physical examination, only by history; second, the symptoms are present only when the person initiating the symptoms is providing care (they disappear when care is provided by another person). The parent usually has some degree of medical or child care knowledge obtained through formal education, reading, or Internet browsing. In the hospital, the parent tends to stay with the child constantly, offering to give the majority of care. There is no correlation with this disorder and parental drug and alcohol abuse or with the child being anxious and wetting the bed.

A nurse in a primary care provider's office is performing a comprehensive assessment on a 16-year-old adolescent diagnosed with anorexia.

abdomen is concave hyperactive bowel sounds. Pulses are weak and thready temperature, 95.9°F (35.5°C); heart rate, 55 beats/min; blood pressure, 88/49 mm Hg body mass index (BMI) of 15.2 sodium, 149 mEq/l (149 mmol/l); potassium, 2.9 mEq/l (2.9 mmol/l); hemoglobin, 9 g/dl (90 g/l); hematocrit, 45% (0.45). Rationale: The abdomen should be flat, not concave. This is a common finding in an adolescent with anorexia.Hyperactive bowel sounds are an abnormal finding and should be assessed further.Weak, thready pulses are an abnormal finding and may indicate dehydration.A temperature of 95.9°F (35.5°C) is subnormal (normal: 97.7°F to 98.6°F; 36.5°C to 37.0°C).A heart rate of 55 beats/min indicates bradycardia, which is often seen in an adolescent with anorexia (normal: 60 to 79 beats/min). A blood pressure of 88/49 mm Hg indicates hypotension (normal: 112-128/66-80 mm Hg).A body mass index (BMI) of 15.2 indicates the adolescent is significantly underweight for their height and weight (normal: 18.5 to 24.9).A serum sodium of 149 mEq/l (149 mmol/l) may indicate dehydration (normal: 135 to 145 mEq/l [135 to 145 mmol/l]).A serum potassium of 2.9 mEq/l (2.9 mmol/l) is an abnormal finding and places the adolescent at high risk for developing a cardiac arrhythmia (normal: 3.5 to 5.2 mEq/l [3.5 to 5.2 mmol/l]).A hemoglobin of 9 g/dl (90 g/l) indicates anemia (normal: 11.1 to 15.7 g/dl [111 to 157 g/l]). Awake, alert, and oriented is a normal finding.Lungs that are clear to auscultation is a normal finding.An oxygen saturation of 98% on room air is a normal finding (normal: 95% to 100%)

A school nurse is developing a plan of care for a child with suspected violence between the child's parents. The nurse monitors for which behaviors in the child?

aggressive behavior in school Rationale: Children who have a parent who is violent may be identified because of behavior problems, noncompliance, and aggression in school. Developmental delays occur in children with other disorders. Development of tics or twitches occurs with Tourette syndrome. Compensating by overachieving is not typically related to violence in the home.

A mother has presented with her 2 year old child. She states that the child was talking in earlier months but recently has "kind of withdrawn." The child does not interact with other children or adults much but does enjoy throwing a ball, retrieving it and throwing it again. The nurse realizes that the child needs further assessment for which disorder?

autism spectrum disorder Rationale: Playing alone and lack of interaction with others are typical symptoms related to autism. There are not indicators of learning issues with the child at the current time and no tics are being reported. Hyperactivity is not noted in the child, which would indicate a hyperactivity disorder.

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? Select all that apply.

complete blood cell count metabolic panel Rationale: 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.

A 16-year-old client is highly disruptive in class and has been in trouble at home. The parent recently found the adolescent torturing a cat. When questioned, the adolescent laughed. What condition might the client be suffering from?

conduct disorder Rationale: Adolescents with conduct disorder are often unmanageable at home and disruptive in the community. They have little empathy or concern for others. They may be callous and lack appropriate feelings of guilt, although they may express remorse superficially to avoid punishment. They often blame others for their actions. Risk-taking behaviors such as drinking, smoking, using illegal substances, experimenting with sex, and participating in crime are typical. Cruelty to animals or people, destruction of property, theft, and serious violation of rules are diagnostic criteria. Asperger syndrome is on the autism spectrum, where the child is extremely high in intelligence. Bipolar symptoms consist of wide swings between depression and mania. Tourette syndrome is a condition where motor and vocal tics occur.

A 16-year-old girl is being seen for a long-overdue checkup. Her caregiver has come with her. She is calm, pleasant, and in good spirits. The caregiver reports to the nurse that she is relieved because for the past 6 months the teenager has been lethargic, angry, and sad. The mother reports that since she got her driver's license two days earlier, her child's mood has changed dramatically. Rather than resist this appointment, the girl had simply smiled and said, "It won't matter much, but okay, I'll be ready in a minute." The nurse recognizes that the child's seeming well-being and drastic change in behavior should be further investigated to determine if the child:

is planning to commit suicide. Rationale: Attempted suicide rarely occurs without warning and usually is preceded by a long history of emotional problems, difficulty forming relationships, feelings of rejection, and low self-esteem. Suicidal adolescents may appear suddenly elated after a long period of acting dejected, and might verbalize their hopelessness with statements such as "I won't be around much longer," or "After Monday, it won't matter anyhow." Some deaths reported as accidents, particularly one-car accidents, are thought to be suicides.

A young parent brings the school-aged child to the office for a sports physical examination. During the appointment, the parent informs the nurse about being worried because the child does not like school and does not seem to be reading, writing, or spelling as well as others in the class. The parent adds that the child struggles to get organized and to manage time. What condition does the nurse suspect?

learning disorder Rationale: The child appears to have a learning disorder based on challenges with reading, spelling, and writing as well as being organized and managing time. Other findings consistent with a learning disorder include delayed language development and difficulty discriminating among sounds. Autism spectrum disorder represents a range of disorders characterized by markedly abnormal or impaired development in social interaction and communication. Down syndrome is a condition in which extra genetic material causes delays in how a child develops, both physically and cognitively. Asperger syndrome is a type of autism spectrum disorder.

The nurse is performing a physical assessment of 16-year-old girl who is intellectually disabled. This client attended her local public elementary school through fifth grade and has since been enrolled at a special education school where she has received social and vocational training. She plans on getting a job in the coming month and on living independently in a few years. The nurse recognizes this client's level of intellectual disability as:

mild Rationale: Children with mild intellectual disability exhibit difficulties in acquisition of academic skills and are typically more concrete in their problem solving. Socially, they are observed as less mature, have a limited understanding of risk, and demonstrate poorer affect regulation than similarly aged peers. As adults, they can usually achieve adequate social and vocational skills for minimum self-support and independent living but need guidance and assistance with complex daily living tasks. During early years, these children learn social and communication skills and are often not too distinguishable from average infants or toddlers. They continue to learn academic skills up to about a sixth-grade level. As adults, they can usually achieve social and vocational skills adequate for minimum self-support. They're able to live independently but need guidance and assistance when faced with new situations or unusual stress.

The nurse is working with a child diagnosed with encopresis. After a complete medical workup has been done, no organic cause has been found for the disorder. What follow-up will the nurse expect?

referred for counseling Rationale: Encopresis is the repeated involuntary passage of feces of normal or near-normal stool in places not appropriate for that purpose. If no organic causes (e.g., worms, megacolon) exist, encopresis indicates a serious emotional problem and a need for counseling for the child and the family caregivers. Medications such as methylphenidate are used for hyperactivity. The diet needs to be high fiber. Antidiarrheals are contraindicated because they can cause more constipation. Lubricant laxatives should be used.

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. Rationale: 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.

Which sign or symptom suggests depression in a child?

somatic complaints and acting-out behavior Rationale: Signs of depression in children and adolescents include depressed or irritable mood, psychomotor agitation/slowness, changes in appetite and sleep, physical complaints, depressive themes, social withdrawal, intense anger or rage, anhedonia, acting-out behaviors, decreased ability to think, thoughts of and verbalizations about death, and specific stressors (e.g, a breakup with a boyfriend or girlfriend). The inability to sit still would be associated with attention deficit hyperactivity disorder. Repetitive behaviors are associated with a child on the autism spectrum. The fear of leaving home is associated with agoraphobia.

Which behavior typical of children with autism spectrum disorder (ASD) requires the nurse to maintain special care to keep them safe?

Insensitivity to pain Rationale: A number of children with autism spectrum disorder may have a hyposensitivity to pain. Thus, if they hurt themselves, they may not feel the associated pain. It is why one can see these children biting themselves or head banging and not feeling any pain. Having cravings, a fascination with colors, and hearing loss may or may not be associated with a child on the autism spectrum but these manifestations would not be associated with safety.

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. Rationale: 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.

An adolescent has been diagnosed with oppositional defiant disorder. Which symptom does the nurse anticipate?

angry outbursts directed at authority figures Rationale: Oppositional defiant disorders (ODD) consist of a pattern of irritability, defiant behaviors, and vindictiveness that result in disturbed functioning in academic and social domains. Children and adolescents with ODD typically have difficulty controlling their temper; such anger is often directed at an authority figure. It is important to distinguish behavior that is within normal limits from behavior that is symptomatic. Many teens demonstrate some defiance toward their parents, but it typically does not disrupt their academic and social relationships like ODD. Problems do not typically occur between siblings and peers, rather with authority figures. Children with ODD may have conflict with legal authorities, but this is not something the nurse would anticipate.

What potential side effect of smoking crack should the nurse teach adolescents about to ensure their understanding of the drug's possible impact?

cardiac arrest Rationale: Adolescents who smoke crack run the chance of having a cardiac arrest due to the rapid absorption of crack into the blood stream. Cocaine usage and crack makes the body temperature rise, the high lasts a short amount of time, usually 5 minutes, and the rapid high is followed by a rapid crash that resembles depression.

The nurse is preparing a teaching plan for the parents of a 9-year-old child with an intellectual disability. Which issue is specific to the child's condition?

difficulty obtaining health care services Rationale: Obtaining adequate health care services for a child with an intellectual disability can be difficult because reimbursement is insufficient and there is a dearth of competent professionals willing to serve this type of client. Changes in living environment and strict adherence to daily routines are problems encountered in children with autism spectrum disorder. Teachers become frustrated with children with learning disorders when they are not aware of the cause of poor performance.

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

dyslexia. Rationale: 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 football coach notices that one of the players has been more energetic and overly happy lately during practice. The player also got in fight with a teammate last week. The coach contacts the health care provider, concerned that the student is using anabolic steroids. What physical sign would the nurse advise the coach to be on the lookout for that would further validate the illicit drug use?

gynecomastia Rationale: Anabolic steroid use can cause periods of euphoria and decreased fatigue, not more fatigue. Gynecomastia is a common side effect of prolonged steroid use, as well as liver damage, hypertension, psychotic episodes, and aggression. Headaches and fainting are not side effects of steroid use.

The nurse is examining a child with fetal alcohol spectrum disorder. Which assessment finding should the nurse expect?

low nasal bridge with short upturned nose Rationale: Typical facial features in an infant with fetal alcohol spectrum disorder 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 fetal alcohol spectrum disorder. Clubbing of fingers is associated with chronic hypoxia.

A child is diagnosed with a mental health disorder and is receiving milieu therapy in an inpatient psychiatric setting. Which actions would the nurse likely include to maintain a therapeutic milieu? Select all that apply

making client rounds every 15 minutes role modeling appropriate interactions with others de-escalating aggressive or anxious behavior Rationale: Milieu therapy, environmental structuring and management, is conducted in dynamic, specially structured settings designed to assist in the overall therapeutic process. During milieu therapy, the environment is arranged to promote therapeutic goals, such as diminishing aggressive behavior and developing adaptive and social skills. Client rounds are made every 15 minutes or more often if necessary. The nurse role-models appropriate interaction with clients, family members, and other staff members and closely monitors behavior of all clients, anticipating escalation of aggression, anxious behavior or any threat to the safety of the client, staff, or peers. The nurse de-escalates aggressive or anxious behavior and takes action to maintain a safe and secure milieu. Family involvement in care is encouraged. The nurse also maintains a risk-free environment.

Which approach to drug education would be most effective for a group of school-age children?

providing the children with strategies of how to refuse offers of drugs Rationale: By fostering self-esteem and empowering children to stand up against drugs and providing them with strategies to avoid drugs when offered to them, parents and health care providers can make an impact on children's behavior and positively influence them to resist drugs when offered to them.

The nurse is caring for an adolescent diagnosed with anorexia nervosa. Which education will the nurse include in the client's discharge teaching?

referrals to counseling services Rationale: Adolescents with eating disorders need to increase self-esteem or a feeling that they have control over their life. This can be achieved through extensive counseling services, which should be scheduled for this client prior to discharge. The client needs to be nutritionally stable before participating in exercise activities. Desensitization is not a method of treatment used for anorexia. It is used to diminish emotional responsiveness to a stimulus through repeated exposure. Phenelzine, a monoamine oxidase inhibitor (MAOI), is not used to treat anorexia. It is used to treat depression. Selective serotonin reuptake inhibitors (SSRIs) and antipsychotics are typically used to treat clients with anorexia nervosa.

A 7-year-old child being treated for depression will most likely be given which first-line pharmacologic treatment?

selective serotonin reuptake inhibitors (SSRIs) Rationale: The most commonly used antidepressant medications for children and adolescents are SSRIs. Side effects, especially nausea, headache, and stomachache, are minimal, especially when the starting dose is low with a gradual increase to a therapeutic level. Benzodiazepines are prescribed for anxiety, not depression. Tricyclic antidepressants are an older class of antidepression drugs. They have many more side effects and are not widely used. MAOIs are the first class of antidepressants ever made. They have many interactions with food and are not prescribed for children.