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

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 She states that the child was talking in earlier months but recently has "kind of withdrawn."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 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.

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

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

The 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?

Medical child abuse Repeated hospitalizations that fail to produce a medical diagnosis, transfers to other hospitals, and discharges against medical advice are warning signs of Medical child abuse (Münchhausen syndrome by proxy).

A child with an intellectual disability is evaluated and found to have an intelligence quotient (IQ) of 65. The nurse interprets this as reflecting which category of intellectual disability?

Mild Mild intellectual disability involves an IQ from 50 to 70. Moderate intellectual disability involves an IQ from 35 to 50. Severe intellectual disability involves an IQ from 20 to 35. A profound intellectual disability involves an IQ less than 20.

A child is suspected of having bipolar disorder. What would the nurse identify if the child was experiencing a manic episode? Select all that apply.

Pressured speech Decreased sleep Flamboyant behavior Manifestations associated with a manic episode include rapid, pressured speech; increased energy; decreased sleep; flamboyant behavior; and irritability. The child also may demonstrate an increase in risk-taking behaviors, resulting in accidents and sexual promiscuity.

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

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

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

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

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

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

The nurse is educating parents of a child recently diagnosed with autism. A description of the characteristics of autism are explained within categories. The nurse becomes concerned when the mother states that the categories of autism are associated with:

inability to properly synthesize glucose. The nurse would be concerned about the mother's understanding of the characteristics of autism if she includes synthesis of glucose as a category. Glucose synthesis is not related to autism. The other choices are all categories of symptoms for the child with autism.

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

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

The nurse is working with a child diagnosed with encopresis. After a complete medical workup has been done, no organic cause has been found for the disorder. The nurse will anticipate the child will next be:

referred for counseling. 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.

The nurse is caring for a 12-year-old boy who is profoundly cognitively challenged, 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 cognitively challenged 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 cognitive challenge, including mild (live independently as an adult), moderate (perform unskilled manual labor), and severe (dress himself).

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." 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.

The nurse is discussing the treatment for a child with attention deficit hyperactivity disorder (ADHD) with a group of school nurses. What would be an appropriate learning setting for a child with ADHD?

A classroom with a plan of study that is followed each day. For the child with ADHD the learning situations should be structured so that the child has minimal distractions and a supportive teacher. Special arrangements can be made to provide an educational atmosphere that is supportive for the child without the need for the child to leave the classroom.

The nurse is caring for several adolescent clients on the mental health unit. Which clients should the nurse suggest to join a group therapy session? Select all that apply.

Adolescents with depressive disorder Adolescents with a history of drug abuse Adolescents who have experienced rape Adolescents who have experienced the death of a loved one In group therapy, feelings are expressed and participants gain hope, feel a part of something, and benefit from role modeling and talking with others that have been through the same experiences. The adolescent that is experiencing uncontrolled aggressive behavior would not be a good candidate for group therapy as he may become more aggressive; this would also make the participants uneasy to attend group.

The nurse is preparing a presentation for a local health fair on autism spectrum disorders. What statement would the nurse include as part of the presentation?

Autism cannot be cured. There are no medications or treatment available to cure autism. Behavioral and communication therapies are very important in caring for a child with autism. Children with autism spectrum disorder respond very well to highly structured educational environments. To date, complementary and alternative medical therapies have not been scientifically proven to improve autism.

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

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

The 18-month-old toddler has been brought into the pediatrician's office by his parents. The nurse interviews the parents regarding the child's abilities. Which findings are warning signs that the toddler may have autism spectrum disorder? Select all that apply.

Has never "babbled" Does not exhibit attempts to communicate by pointing to objects Does not use any words An 18-month-old toddler should have babbled by 12 months. He should be using gestures and using single words to communicate. The use of sentences to communicate and the ability to stand on tiptoe would be expected later.

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

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

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

Insensitivity to pain A number of children with ASD demonstrate poor sensation of pain and, thus, bite their hands or bang their heads repeatedly.

The nurse is caring for a 10-year-old recently diagnosed with attention deficit/hyperactivity disorder (ADHD). The nurse would expect to provide teaching regarding which medication?

Methylphenidate Methylphenidate is a psychostimulant commonly prescribed for ADHD. Trazodone is used to treat depression. Buspirone is used for anxiety. Fluoxetine is used for depression.

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

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

The child has been diagnosed with attention deficit hyperactivity disorder (ADHD) and has begun taking methylphenidate. Which findings are most likely adverse effects related to this medication? Select all that apply.

Occasional headache Increased irritability Abdominal pain Common side effects related to the use of psychostimulants are: headaches, irritability, and abdominal pain. Children typically exhibit a decreased appetite and may have difficulty with insomnia.

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.

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

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

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

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 lost 10 pounds over the last 4 months." "He has started sleeping for only 3 hours each night." "He used to be a straight-A student and now he's bringing home Cs and Ds." 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.

The child has been diagnosed with a mental health disorder and the child's parents are beginning to incorporate behavior management techniques. Which statements by the child's parent indicate the need for further education? Select all that apply.

"I am quick to point out the things that she does that make me crazy." "I use a higher pitched voice when I communicate with her." The parents should use a calm, low-pitched voice when communicating with her. They should ignore inappropriate behaviors. The parents should not argue or bargain with the child about set limits. They should praise the child for accomplishments and help the child see the importance of accountability for her own behavior.

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." 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.

When can autistic behaviors first be noticed?

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

Which behavior demonstrated by a boy with ADHD is most indicative of the syndrome?

A lack of concentration As the name implies, children with ADHD are unable to concentrate on an activity for the usual length of time.

Which children would be best characterized as having a separation-anxiety disorder?

An 8-year-old who will not stay overnight at a friend's house A separation-anxiety disorder suggests a child is unwilling to be separated from a parent; this is normal in an 8-month-old but not in older children.

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

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

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

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

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

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

The nurse is collecting data on a 16-year-old girl with the diagnosis of bulimia. What would the nurse most likely note in this child?

The child is of normal weight for her height according to the growth charts. The typical bulimic person is a white female in late adolescence. Most often, the bulimic person is of normal weight or is slightly overweight.

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

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

The drug most commonly abused by children and adolescents is:

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

An adolescent comes to the office of 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?" Health professionals involved with children and family caregivers must be aware of hints that signal an impending suicide attempt. Some of these desperate young people will verbalize their hopelessness.

The nurse is providing teaching about the potential side effects of lithium for the parents of a girl recently diagnosed with bipolar disorder. Which statement by the parents indicates a need for additional teaching?

"If she loses weight, then we know the medication is working." Weight gain, not weight loss, is a side effect of the drug. An increased appetite occurs with lithium. Lithium is associated with tremors and nausea. Polyuria occurs with lithium

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.

After teaching the parents of a child with Tourette syndrome about motor and vocal tics, the nurse determines that the teaching was successful when the parents state:

"If we get him focused on an activity, the tics will be less pronounced." Tics become more noticeable or severe during times of stress and less pronounced when the child is focused on an activity such as watching TV, reading, or playing a video game. The tics are not under voluntary control and either type can be difficult to control. Management is highly individualized and involves psychopharmacology and behavioral therapy.

The mother of a 2-month-old infant questions the nurse about autism. She reports a close family member has a child with this disorder and she is concerned about her child. What information can be provided to the child's mother? Select all that apply.

"In infancy a lack of loving behaviors such as cuddling is concerning." "Infants who are on the autism spectrum may have difficulty establishing or maintaining eye The spectrum of autism disorder ranges from mild (e.g., Asperger syndrome) to severe. Autistic behaviors may be first noticed in infancy as developmental delays or between the age of 12 and 36 months when the child regresses or loses previously acquired skills. The exact etiology of autism continues to elude scientists, but it may be due to genetic makeup, brain abnormalities, altered chemistry, a virus, or toxic chemicals. Children with ASD display impaired social interactions and communication. They may fail to develop interpersonal relationships and experience social isolation.

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

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

The mother of a 6-year-old child recently diagnosed with mild to moderate cognitive delays is tearful. She questions if her child will need to be institutionalized and attend special schooling. What response by the nurse is indicated

"Most children with cognitive issues are able to attend regular schools. Today, most children with cognitive and developmental concerns are able to attend public schools. This is in contrast to schooling options in past decades.

The nurse talks with family of a child with dysgraphia. The parents state, "We are so frustrated with the school. They just keep saying that our child doesn't fit into the classroom well." The child tells the nurse, "I don't know why I can't do well on my school work like my friends." Which responses from the nurse are appropriate? Select all that apply.

"The Individuals with Disabilities Act (IDEA) ensures your child's right to assistance at school based on the disability. I would suggest you talk to the school counselor about this." "Your child will need an individualized education plan (IEP) that reflects her particular needs. If you need documentation of the disability we can provide it." "There are some resources I can provide you with that may help you with caring for your child." "Please let me know if there is anything we can do to help you with your child at school. It must be very frustrating for you all." Showing empathy, offering support, educating the family about right and resources are all ways that can help the family is supporting the child's educational needs. The nurse should not speak negatively about the school or suggest contacting the superintendent. This behavior doesn't help get the services the child needs in an effective manner.

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

The nurse is working with a group of caregivers of school-age children diagnosed with attention deficit hyperactivity disorder. Which statement would be most appropriate for the nurse to make to this group of caregivers?

"The medications your child is on may cause a decreased appetite." Learning situations should be structured so that the child has minimal distractions. Structured, consistent guidance from the caregivers is needed. Medication is used for some children, and these medications may suppress the appetite and affect the child's growth. The child should be given only one simple instruction at a time. Limiting distractions, using consistency, and offering praise for accomplishments are invaluable.

The nurse is discussing teenage substance abuse with a group of caregivers of adolescent children. If the caregivers make the following statements, which statement is the most accurate regarding substance abuse in teens?

"The most common drug used by teenagers is alcohol." Alcohol is the most common mind-altering substance used by adolescents, and its use or use of tobacco or other substances in adolescence can lead to serious concerns.

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

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

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 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 ADHD is placed on methylphenidate (Ritalin) therapy. What symptom may children on Ritalin develop?

Anorexia Ritalin typically causes a loss of appetite. Weighing the child periodically to detect whether this has led to a loss of weight is important.

A group of nursing students are reviewing medications used to treat attention deficit/hyperactivity disorder (ADHD). The group demonstrates understanding of the information when they identify what as a nonstimulant norepinephrine reuptake inhibitor?

Atomoxetine Atomoxetine is a nonstimulant norepinephrine reuptake inhibitor used to treat ADHD. Methylphenidate is a psychostimulant used to treat ADHD. Lisdexamfetamine is a psychostimulant used to treat ADHD. Pemoline is a psychostimulant used to treat ADHD.

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 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 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.

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

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

A 10-year-old girl has been referred for evaluation due to difficulties integrating with her peers at her new school. The counselor believes she is at risk for situational low self-esteem due to problematic relationships with both family members and peers. What is the best approach?

Engage the girl in dialogue regarding feelings about self/personal appearance. Engaging the child in dialogue about self and personal appearance may reveal self-perceptions and allow discussion of reality versus perception; this enables discussion of methods to address perceived weaknesses and to focus on strengths. Appearance may reflect self-perception, and a comment regarding hygiene might be poorly received. While pubertal changes can be stressful, a 10-year-old girl may not have entered puberty and the question may not be relevant. The concept of accepting differences is secondary to engaging child in dialogue about self and appearance.

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

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

The nurse is assessing a newly admitted 14-year-old and notes that he makes very little eye contact, becomes very frustrated with questions and conversation, and does not smile or laugh. What nursing diagnoses will the nurse add to the care plan based on these assessment findings? Select all that apply.

Impaired social interaction Ineffective individual coping Limited eye contact lack of smiling support the nursing diagnosis of Impaired social interaction. Becoming frustrated easily with conversation supports both Impaired social interaction and Ineffective individual coping.

The nurse is performing a physical assessment of 16-year-old girl who is cognitively challenged. 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 cognitive challenge as:

Mild About 85% of children who are cognitively challenged have an IQ of 50 to 70 and may be referred to as "educable" by a school system. 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.

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

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

The nurse is conducting an examination of a boy with Tourette syndrome. Which finding should the nurse expect to observe?

Sudden, rapid stereotypical sounds Sudden, rapid, stereotypical sounds are a hallmark finding with Tourette syndrome. Toe walking and unusual behaviors such as hand-flapping and spinning are indicative of autism spectrum disorder (ASD). Lack of eye contact is associated with ASD but is also noted in children without a mental health disorder.

The nurse is obtaining the history of an adolescent female who is suspected of having anorexia nervosa. What findings would the nurse expect? Select all that apply.

Syncope Desire for perfectionism Secondary amenorrhea The adolescent with anorexia may have a history of constipation, syncope, secondary amenorrhea, abdominal pain, and periodic episodes of cold hands and feet. In addition, the child's self-concept reveals multiple fears, high need for acceptance, disordered body image, and perfectionism.

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

The child cannot properly dress herself. 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.

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

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

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

The child constantly opens and closes his hands. 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.

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

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

A mother brings her 15-year-old girl to the gynecologist's office for a physical examination. The mother pulls the nurse to the side and says that she is concerned that her daughter may have an eating disorder. Which finding would tend to confirm a diagnosis of anorexia nervosa?

The girl repeatedly describes herself as "fat" even though she appears to be severely underweight Anorexia nervosa is characterized by refusal to maintain a minimally normal body weight because of a disturbance in perception of the size or appearance of the body. Characteristics of a child with anorexia nervosa include the following: severely distorted body image; a BMI of less than 17.5 or less than 85% of expected weight; intense fear of gaining weight or becoming fat though underweight; refusal to acknowledge the seriousness of weight loss; and amenorrhea—absence of menstruation or period (in girls).

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 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 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.

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

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

Contract agreements are often recommended for clients with eating disorders. In forming a contract with a hospitalized adolescent diagnosed with anorexia nervosa, the nurse should make a point to:

stress to the client that she is in control of the outcome of her care. Contract agreements are often recommended for people with eating disorders. These agreements, which are usually part of a behavioral modification plan, specify the child's and the staff's responsibilities for the diet, activity expectations for the child, and other aspects of the child's behavior. The contract also may spell out specific privileges that can be gained by meeting the contract goals. This places the child in greater control of the outcome.

The nurse is meeting with a family that has learned that their 11-year-old daughter has some intellectual disabilities. They tell the nurse that she is having trouble coping with different situations at school. What is the best response the nurse could give?

"Coping and adaptation are often affected by intellectual disabilities." The child is at increased risk for adjustment disorders because the child's coping strategies are not understood or recognized and his or her range of adaptive strategies may be reduced. Coping, adaptation, and social skills development are greatly dependent on abstract thinking and the ability to generalize from one situation to another. Abstract thinking is impaired in intellectual disability. Children who have intellectual disability are often uncomfortable with unfamiliar surroundings and people. Time is needed to build relationships.

The nurse is interviewing a depressed 13-year-old girl. During the course of the interview, the girl reveals that her best friend is thinking about committing suicide. How should the nurse respond?

"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 to gather this information and open a dialogue to encourage the girl to reveal she is talking about herself. The other questions would not elicit the critical information about the method of suicide.

A 15-year-old girl has been evaluated and diagnosed with major depression. The advance practice mental health nurse has prescribed paroxetine (Paxil), a selective serotonin reuptake inhibitor. The mother of the girl refuses to let her take the medicine because she has read about several suicides of teenagers who have been on this medicine. What should the nurse say to address the mother's concerns?

"Let's sit down and talk about your concerns." It is critical to educate the mother about the medicine. A one-on-one dialogue will allow the nurse to stress the importance of taking the medicine daily, the length of time it will take to be effective, and the importance of not stopping the medication abruptly. The nurse should stress the value of pharmacotherapy and cite the research supporting the benefits versus the anecdotal evidence in the media. Dismissing the mother's concerns is not effective. It is best to address the mother's concerns in private and then elicit the support and understanding of the girl. Telling the mother that the daughter must start the medicine does not address the mother's concerns.

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

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