Peds - Ch. 50: Alteration in Behavior, Cognition, Development or Mental Health/Cognitive Disorder

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. 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 intellectual disability. Decrease in head circumference suggests malnutrition or decelerating brain growth. A long face and prominent jaw are symptoms of Fragile X syndrome.

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

Not punishing the child for encopresis 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.

A nurse is examining a 4-year-old child with various injuries in multiple places. Which site of injury would introduce suspicion of abuse?

abdomen The abdomen is the most frequent site of physical injury where abuse is suspected in children 4 years of age and younger. If injuries to the soles and palms are present, the nurse should look into inflicted burns as a possible cause of injury.

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?" 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.

A nurse taking a health history from an adolescent female would become concerned about anorexia if the adolescent made which statement?

"I've been really tired lately, but I'm afraid that if I rest I will get fatter than I am already." Clients with anorexia view themselves as fat even though they are emaciated and have a skeleton-like appearance. Stating that she is tired, another symptom of anorexia, along with the feeling that she is already fat both are warning signs for anorexia nervosa. If the adolescent's weight is also very low, this would also concern the health care provider.

The nurse is providing teaching about medication management of attention deficit hyperactivity disorder (ADHD). Which response indicates a need for further teaching?

"If he takes this medicine he will no longer have ADHD." It is important to remind the parents that medications for the management of ADHD are not a cure but help to increase the child's ability to pay attention and decrease the level of impulsive behavior. The other statements are correct.

A nurse is explaining the difference between anorexia nervosa and bulimia nervosa. The nurse knows the teaching was effective when the parents make which statement?

"Individuals with bulimia have a normal weight or are slightly overweight." Individuals with bulimia are often a normal weight or slightly overweight, and therefore the problem may escape notice from friends and family. Bulimia refers to recurrent and episodic binge eating and purging by vomiting, accompanied by awareness that the eating pattern is abnormal, and yet the individual is not able to stop the pattern. Both of these disorders are life threatening. With either type of bulimia, the combination of frequent vomiting and use of laxative or diuretics can result in such serious physical complications, notably electrolyte abnormalities, which can ultimately lead to effects as severe as cardiac arrest. In teens with anorexia, the nurse may observe significant hypotension, hypothermia, and bradycardia. If the process is allowed to continue without therapy, it can lead to starvation, serious health problems, and even death. Laboratory analysis may reveal anemia and leukopenia, an elevated BUN and creatinine levels, hypercholesterolemia, and elevated liver enzymes; endocrine studies may reveal a low T3 and T4 while reverse T3 levels may be elevated. An electrocardiogram commonly demonstrates bradycardia and may include arrhythmias or a prolonged QTc interval. Adolescents with purging may develop severe erosion of their teeth because of the constant exposure to acidic gastrointestinal juices from vomiting. Russell sign (scars or calluses on the dorsal side of the hand from repeated contact of the teeth while inducing vomiting) might be present in those who engage in purging behavior.

A 10-year-old girl with 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. 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.

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." 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.

While interviewing a depressed adolescent, it is revealed that the client has considered hurting oneself. What question is the nurse's priority?

"Tell me exactly how you would hurt yourself." It is important for the nurse to find out exactly how the adolescent is envisioning harming oneself. This information will help the nurse to take measures to prevent an attempted suicide. The other questions are important to ask, but are not the priority. They do not elicit the necessary information to prevent an attempt.

The school-aged child has been diagnosed with dysgraphia and dyslexia. Which statement(s) by the child demonstrates an understanding of these disorders? Select all that apply.

-"I may have difficulty writing." -"I may have difficulty spelling words." Children diagnosed with dyslexia and dysgraphia experience difficulty with reading, writing, spelling, and producing written words. Sensory processing disorder may result in hypersensitivity to sensory input (vision, hearing, touch, etc.). It may be mistaken for a learning disorder, but it is not and should be treated differently. Children with dyspraxia have problems with manual dexterity and coordination.

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. 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.

The nurse is completing the physical assessment of a 12-year-old child who has a series of bruises in various stages of healing. When asked about the bruises the child appears frightened and offers inconsistent accounts about how the child got the bruises. The nurse suspects abuse. Which initial action of the nurse is most appropriate?

Document the bruises and any statements made by the child relating to them. Nurses in each state have a legal requirement to report suspicions of child abuse or maltreatment. The nurse must document all findings. The medical record will be of importance in establishing the findings. Once the findings are documented, the nurse will need to closely follow the agency policies regarding the reporting process. The nursing supervisor will need to also be involved but that will take place after the documentation has been completed. The child cannot be photographed without appropriate approvals. The child may indeed be asked to provide a more detailed reporting of the bruising, but it is not the role of the nurse to request it. The child's parents will also become a part of the investigation but the interviewing process does not come before the documentation of the findings.

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.

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 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.

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 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 nurse has been working for several days with an adolescent who has anorexia nervosa. What is an indication that the adolescent is developing trust in the nurse?

The adolescent telling the nurse purging occurs after each meal. The adolescent with anorexia tends to have many fears and a high need for acceptance. Therefore, trust is difficult for this adolescent. Trust has to be gained from an adult before the adolescent can share confidences. Purging after every meal with anorexia is common and one of the goals of therapy is to stop the purging. It is often done in secret. When the adolescent has gained trust in the nurse then the adolescent will begin to share the number of times purging has been happening. When the adolescent is making statements such as liking one nurse more than another or following one nurse's instructions and not the others, this is manipulation. It is not healthy. The adolescent stating a desire to eat again could be interpreted two ways. The adolescent could be getting healthier with therapy or it could also be seen as manipulation and a way to purge more often. Either way, it is not a sign that trust has developed.

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. 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.

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. 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.

While obtaining a health history, the nurse notices that the child has a history of pica. The nurse needs to be aware of which possible condition associated with pica?

The child could have a developmental or learning disability. It is not uncommon for a child who has a developmental or learning disability to have poor nutrition or malnutrition in the first years of his or her life. It is also common for children with these disabilities to suffer from pica. Pica includes ingesting non-nutritive material such as paint, clay, or sand. The child may later be diagnosed with autism spectrum disorder. Down syndrome is a genetically inherited disorder.

The nurse in the well-child clinic observes that a 5-year-old child in the waiting room is having trouble using a crayon to color. During the visit, the same child climbs off the table several times even after the nurse has asked him to stay on the table. Each time the nurse reminds him he says, "Oh, yeah," and happily climbs back up. The nurse suspects that the child has:

attention deficit hyperactive disorder (ADHD). The child with ADHD may have these characteristics: Impulsiveness, easy distractibility, frequent fidgeting or squirming, difficulty sitting still, problems following through on instructions despite being able to understand them, inattentiveness when being spoken to, frequent losing of things, going from one uncompleted activity to another, difficulty taking turns, frequent excessive talking, and engaging in dangerous activities without considering the consequences.

What is the most difficult risk factor for a child to overcome related to substance abuse?

home environment where there is drug or alcohol abuse Children who are exposed to family members who abuse alcohol or drugs are the least influenced by educational programs promoting abstinence from drugs. Their home environment has a great impact on how they view substance abuse.

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

selective serotonin reuptake inhibitors (SSRIs) 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.

Which sign or symptom suggests depression in a child?

somatic complaints and acting-out behavior 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.

A nurse is teaching a group of parents about risks for mental health disorders in children. Which factors does the nurse include in this teaching session?

trauma, poverty, neglect Various factors have been associated with an increased risk for mental health disorders in children, including trauma, poverty or neglect, difficult temperament or attachment problems, medical illness, or major losses to the family such as divorce or death. Stress could be an issue, but prematurity and poor nutrition are not risk factors for mental health disorders. Death in the family or divorce can cause mental health issues as well as illness, but intellectual disability does not. Developmental delay may be a symptom of a problem, but it is not a risk factor. Anoxia at birth is can cause cognitive disability and possible learning problems, but these are not risk factors for mental illness in themselves.

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." 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 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.

A pediatric client has recently been prescribed methylphenidate. The parent calls the office and insists the medication is not working. How will the nurse respond?

"Tell me why you believe the medication is not working." Asking the parent to explain why he or she believes the medicine is not working will offer important insights into the parent's definition of effectiveness. It is important for both the parent and health care team to develop a shared definition of effectiveness and improvement. Once this is established, the nurse can suggest the next step in the treatment plan. Stating a different medication or dosage may be needed does not provide any information about the child's response to the current medication. Asking the parent about administering the medication properly could cause the parent to take offense and does not provide the necessary information.

The parents of a 13-year-old tell the nurse that they have done some research and they think their daughter has conduct disorder. The parents report the child excessively argues with them, throws tantrums when not getting her way, and stays mad at them for long periods of time. How should the nurse respond?

"The behavior you are describing sounds more like oppositional defiant disorder than conduct disorder." Oppositional defiant disorder is characterized by excessive arguing with adults, frequent temper tantrums, active defiance, revenge-seeking behaviors, frequent resentment or anger, and touchiness or easily annoyed. Conduct disorder has a host of other behaviors for the criteria of the diagnosis.

During a wellness health check, a 10-year-old child reports not liking school because the child is getting picked on by other children. The child's parents state a desire to know what the child did to cause the bullying. Which statement by the nurse is most therapeutic?

"The most important thing for your child to understand is that he or she is not to blame for the bullying." Bullying is experienced by children during the school-age period. The child being bullied may be picked on due to a perceived difference between the child and peers. These differences include size, religion, manner of dress, or a physical/cognitive delay or impairment. Being bullied is stressful and causes anxiety for the victim. It is most important for the nurse to reinforce to the child and parents that this is not the child's fault. While it is important to determine the presence of injuries and to also report the events to the appropriate personnel, it is most important that the child and family be aware that the child is without blame.

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

-hypothermia -orthostatic hypotension -weak pulse 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.

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 -de-escalating aggressive or anxious behavior -role modeling appropriate interactions with others 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.

The nurse is caring for a 12-year-old boy who is profoundly intellectually disabled, with an IQ of 15. Which task is the most challenging that the nurse should expect this client to be able to accomplish as an adult?

Brush his teeth The IQ of children in this group is less than 20. Fewer than 1% of intellectually disabled children fall into this group. Such children demonstrate only minimal capacity for sensorimotor functioning. Some are able to respond to training in minimal self-care, such as tooth brushing, but only very limited self-care is possible. They need a highly structured environment and a constant level of help and supervision for safety. The other answers refer to other levels of intellectual disability, including mild (live independently as an adult), moderate (perform unskilled manual labor), and severe (dress himself).

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 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.

The health care provider has recently informed parents that their child has an intellectual disability. The parents express the need for information and help with the important decisions they need to make concerning care of their child. What is an appropriate nursing diagnosis for this situation?

Parental knowledge deficit related to health care needs for a child with an intellectual disability Parental knowledge deficit related to health care needs for a child with an intellectual disability is the best nursing diagnosis for this situation because it addresses the parental need for information. There may be anxiety, ineffective family coping, and ineffective family process, but there is no data to support that in this situation.

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. 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.

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 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 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.

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 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.