241 Mod 8 - Practice Questions

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

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

Which assessment finding(s) of a child would cause the nurse to suspect autism spectrum disorder (ASD)? Select all that apply. A) A sibling with autism B) Repetitive hand gestures C) No eye contact D) Responding to gestures from the staff E) Delayed speech

A, B, C, E. The highest risk factor for a child to be considered autistic is having a sibling with autism. Autism clients signs and symptoms include repetitive hand gestures, having no eye contact, and delayed speech. Repetitive hand gestures like clasping hands over and over again. The clients also have repetitive sounds, counting, or repeating the same word over. These clients also do not like eye contact. They avert their eyes if someone tries to make eye contact. Clients also have delayed speech development. They have difficulties answering questions or talking directly to another person.

Which descriptive term(s) reflect(s) common characteristics associated with autism spectrum disorder (ASD)? Select all that apply. A) Ritualistic B) Expressive C) Repetitive D) Social E) Affectionate

A, C. Clients with ASD have characteristic physical and mental conditions. Ritualistic behaviors, including a need to place objects in a certain order or do certain things in the same order is common in clients with ASD. A need for routines and daily schedules are especially needed when clients are in a facility. This helps ease anxiety. Many clients with ASD have repetitive behaviors such as flapping hands or twisting fingers. Communication difficulties and developmental delays interfere with making friends or communicating with others so these clients are not social individuals. Clients with ASD are not generally expressive or affectionate, rather they often do not have appropriate facial expressions or gestures and have difficulty expressing emotions or affection. Social distancing is more comfortable for this client, therefore, they tend to prefer being alone and distant from others.

Which of the following interventions should a nurse anticipate implementing when planning care for children diagnosed with attention deficit-hyperactivity disorder (ADHD)? Select all that apply. A. Behavior modification B. Antianxiety medications C. Competitive group sports D. Group therapy E. Family therapy

ANS: A, D, E The nurse should anticipate that behavior modification, group therapy, and family therapy may be implemented in the management of ADHD in children. These interventions are often used in conjunction with psychopharmacology to reduce impulsive and hyperactive behaviors and to increase attention span.

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

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

Which nursing diagnosis is most associated with an untreated adolescent client with attention deficit hyperactivity disorder? A) Risk for injury B) Loss of energy C) Anxiety D) Impaired communication

A. Attention Deficit Hyperactivity Disorder (ADHD) is a disorder caused by a decrease in dopamine and norepinephrine. ADHD can be treated with behavioral therapy and medication. ADHD symptoms of impulsive behavior puts the client at risk for self injury. The adolescent client does not intentionally cause self-harm but inadvertently can cause injury through careless, impulsive actions. They may experience falls, running into objects, touching things that can harm them, etc. Therefore, the client should be monitored carefully to reduce the incidence of injury. This is especially true if the client is not medicated.

When making the care plan for a 16 year old client with ADHD who is at risk for self harm due to impulsive behaviors, which of the following is a nursing priority? A) Assign the client for 1:1 observation B) Allow the client to be unsupervised C) Place the client in seclusion D) Give the client strict rules

A. Attention Deficit Hyperactivity Disorder(ADHD) is a disorder caused by a decrease in dopamine and norepinephrine. ADHD can be treated with behavioral therapy and medication. ADHD symptoms of impulsive behavior puts the client at risk for self harm. Therefore these clients must be monitored. A staff member will need to be assigned to the client one-on-one observation.

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

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

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

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

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

ANS: A The students evaluation of the situation is appropriate when indicating a need for the client to be evaluated according to developmental norms. Guidelines for determining whether emotional problems exist in a child should consider if the behavioral manifestations are not age-appropriate, deviate from cultural norms, or create deficits or impairments in adaptive functioning.

Which of the following risk factors noted during a family history assessment should a nurse associate with the potential development of intellectual disability? Select all that apply. A. A family history of Tay-Sachs disease B. Childhood meningococcal infection C. Deprivation of nurturance and social contact D. History of maternal multiple motor and verbal tics E. A diagnosis of maternal major depressive disorder

ANS: A, B, C The nurse should associate a family history of Tay-Sachs disease, childhood meningococcal infections, and deprivation of nurturance and social contact as risk factors that would predispose a child to intellectual disability. Major predisposing factors of intellectual disability include: hereditary factors, early alterations in embryonic development, pregnancy and perinatal factors, medical conditions acquired in infancy or childhood, environmental influences, and other mental disorders.

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

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

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

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

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

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

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

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

Which finding would be most likely in a child diagnosed with separation anxiety disorder? A. The child has a history of antisocial behaviors. B. The child's mother is diagnosed with an anxiety disorder. C. The child previously had an extroverted temperament. D. The child's mother and father have an inconsistent parenting style.

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

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

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

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

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

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

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

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

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

The nurse should recognize which of the following findings contribute to a clients development of attention deficit-hyperactivity disorder (ADHD)? Select all that apply. A. The clients father was a smoker. B. The client was born 7 weeks premature. C. The client is lactose intolerant. D. The client has a sibling diagnosed with ADHD. E. The client has been diagnosed with dyslexia.

ANS: B, D The nurse should identify that premature birth and having a sibling diagnosed with ADHD would predispose a client to the development of ADHD. Research indicates evidence of genetic influences in the etiology of ADHD. Studies also indicate that environmental influences such as lead exposure and diet can be linked with the development of ADHD.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

A boy has been diagnosed with ADHD and has been prescribed Ritalin. The boy's mother tells the nurse that she does not understand why a stimulant would help him, stating, If anything, he's completely overstimulated, not understimulated! What should the nurse explain to the mother about the therapeutic use of Ritalin? A) Ritalin helps with the symptoms of ADHD, but the reasons for this are not well understood. B) Ritalin stimulates the parasympathetic nervous system, resulting in increased control of behavior. C) Ritalin stimulates the limbic system, which regulates control over behavior and affect. D) Ritalin enhances the function of dopamine, which regulates cognition.

Ans: A Feedback: The efficacy of Ritalin in ADHD is paradoxical and not well understood. It does not significantly affect dopamine levels or the function of the limbic system and parasympathetic nervous system.

Methylphenidate will be used to treat a 9- year-old boy's ADHD. In light of this drug's most common adverse effects, the nurse whois working with the family should implement what strategy? A) A strategy to ensure that the boy maintains normal bladder function B) A plan to address the boy's loss of appetite C) A plan to enhance the boy's self-esteem D) A strategy to regularly monitor the boy's blood glucose levels

Ans: B Feedback: Like dextroamphetamine, methylphenidate often causes loss of appetite. Plans to address this should be in place at the beginning of therapy. Frequent blood glucose monitoring and actions to maintain bladder function are not likely necessary. Self- esteem should likely be addressed during treatment, but reduced self-esteem is not an adverse effect of methylphenidate.

Which intervention can the registered nurse (RN) suggest for the mother of a twenty month old son who is experiencing separation anxiety when the mother leaves the hospital each day for work? Select all that apply. A) Slip out of the room each day when he is not watching you. B) Leave one of your sweaters here for him to wrap up in. C) Bring his favorite toys that he can play with during the day D) Provide a picture of yourself to leave in the room with your son E) Keep the blanket he sleeps with at home in the hospital bed with him.

B, C, D, E. Although erroneously interpreted by some as a sign of undesirable, antisocial behavior, separation anxiety is an important component of a strong, healthy parent-child attachment. Parents may wonder whether they should encourage the child's clinging, dependent behavior, especially if there is pressure from others who view this as spoiling the child. Parents need to be reassured that such behavior is healthy, desirable, and necessary for the child's optimum emotional development. If parents can reassure the infant of their presence, the infant will learn to realize that they are still there even if not physically present. Talking to infants when leaving the room, allowing them to hear one's voice on the telephone, and using transitional objects reassures them of the parent's continued presence.

The hospitalized 8 year old client with a new diagnosis of ADHD is being prescribed amphetamine. Which of the following side effects will the nurse monitor for? Select all that applies. A) Weight gain B) Dizziness C) Nervousness D) Trouble sleeping E) Nausea

B, C, D, E. The ADHD client on the medication amphetamine will need to be monitored for side effects such as weight loss, insomnia, dizziness, headache, nausea/vomiting, nervousness and loss of appetite. These medications are known as stimulants. This medication helps the client to pay attention and stay focused. The child client will need to be monitored for weight loss and growth. All serious side effects need to be reported to the health care provider as soon as possible.

A 10 year old client who displays hyperactive and impulsive behaviors states that at school he gets in trouble for not paying attention and that he's not as smart as his classmates. The nurse knows this is a behavior of what? A) Anxiety disorder B) ADHD C) Depression D) Attention deficit disorder

B. Attention Deficit Hyperactivity Disorder (ADHD) is a disorder caused by a decrease in dopamine and norepinephrine. ADHD can be treated with behavioral therapy and medication. The signs and symptoms are restlessness, excessive talking, impulsiveness, low self esteem, impaired social skills, etc. These symptoms make it hard to complete a task. Onset usually occurs in childhood and can be difficult for the client to learn at the same rate as their classmates.

The nurse knows which is a symptom of hyperactivity? A) Being attentive B) Loud talking C) Excessive eating D) Somnolence

B. Attention Deficit Hyperactivity Disorder(ADHD) is a disorder caused by a decrease in dopamine and norepinephrine. ADHD can be treated with behavioral therapy and medication. The signs and symptoms are restlessness, excessive talking, impulsiveness, low self esteem, impaired social skills, etc. These symptoms make it hard to complete a task. Onset usually occurs in childhood but can also present in adulthood.

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

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

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

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

A client with autism spectrum disorder (ASD) is preparing to order lunch. Which action would best assist this client? A) Pointing to the pictures of food on a place card B) Limiting the number of choices C) Giving extra choices D) Ordering for the client

B. When giving a choice to a client with ASD it can be a building block to help establish communication. Some clients with ASD have difficulties when making choices or just communicating the choice wanted. One way of helping is to limit the number of choices. Autistic clients may not respond to gestures made by others. So talking will get a better response. When giving extra choices it may confuse or irritate the client. They may not understand what is needed from them. Ordering for the client will not help with teaching responsibility. Letting the client make limited decisions helps build self-esteem.

Which presentation will the registered nurse (RN) expect in the 18 month old male as his mother is separated from him during a procedure? Select all that apply. A) Reaches out to the nurse to be held B) Easily consoled by the nurse C) Screaming as the mother leaves D) Crying when the mother turns to leave E) Searching the room for the mother with his eyes

C, D, E. The major stress from middle infancy throughout the preschool years, especially for children ages 16 to 30 months, is separation anxiety. The phases of separation anxiety include: phase of protest, phase of despair, and phase of detachment. During the phase of protest, the child reacts aggressively to separation from the parent. They cry and scream for their parents, refuse the attention of anyone else, and are inconsolable in their grief. They may continue this behavior for a few hours to several days. Some children may protest continuously, ceasing only from physical exhaustion. If a stranger approaches them, children will initially protest even louder.

Which action will the registered nurse (RN) implement to minimize the effects of hospitalization and separation anxiety for the 28 month old male client? Select all that apply. A) Avoid interacting with the child as much as possible to prevent crying B) Recommend the parent visit only once daily to decrease the good-bye times C) Explain to the mother that playing is not a beneficial action in the hospital D) Talk with the mother to identify the daily routine of the pt E) Arrange the daily care to allow quality sleep time for the pt

D, E. Children and their families require competent and sensitive care to minimize the potential negative effects of hospitalization. A primary nursing goal is to prevent separation, particularly in children under the age of 5 years of age. Implementing family-centered care recognizes the integral role of the family in a child's life and acknowledges the family as an essential part of the child's care and illness experience. Recognizing the importance of continued parent-child attachment fosters an environment that encourages parents to be active caregivers. Altered daily schedules and loss of rituals are particularly stressful for toddlers and early preschoolers and may increase separation anxiety. One technique that can minimize the disruption in the child's routine is establishing a daily schedule. This schedule should include a routine for eating, sleeping, and playing ( as is possible based on the child's illness).

A young autistic client is being assigned a room. Which room assignment is best? A) A private room close to the nurse's station B) A room away from the nurse's station with another autistic client C) A private room near the playroom D) A private room away from the nurse's station

D. A young autistic client needs a private room away from others so that anxiety level stays lowered. A planned routine is in order especially while in a facility. When routines are not followed the client becomes nervous. Also too much stimuli easily agitates the client. An autistic client prefers to play alone. They do not make eye contact easily or sometimes at all. They prefer not to be touched and won't respond to the gestures of others most of the time.

What clinical assessment made by the registered nurse (RN) of a 36 month old female confirms the phase of detachment for separation anxiety? A) Verbal attacks of the RN by the child B) Refusal to eat or drink by the child C) Appears sad while lying with her back to the RN D) Shows interest in what the RN is doing

D. During the third phase of separation anxiety, detachment, the child appears to have finally adjusted to the loss. This phase is also called the phase of denial. The child becomes interested in the surroundings, plays with others, and seems to form new relationships. However, this behavior is a result of resignation and is not a sign of contentment. The child detaches from the parent in an effort to escape the emotional pain of desiring the parent's presence. The child copes by forming shallow relationships with others, becoming increasingly self-centered, and attaching primary importance to material objects. This is the most serious phase because reversal of the potential adverse effects is less likely to occur once detachment is established.

Which is most associated with a client with autism spectrum disorder (ASD)? A) Parents who are older B) Upward slanting of palpebral fissures C) Early vaccinations D) Communication difficulties

D. Knowing what is truth and what is myth helps with dealing with autistic clients. One myth is the client has older parents; another is that early vaccinations cause autism. This has not been proven. Clients with autism have trouble making eye contact. They will avert their eyes and at times turn away. Communication difficulties are very common among autistic clients. The speech development is delayed and they may have echolalia. Echolalia is when a client repeats the words or phrases heard around him. Echolalia is not always a tool to self-sooth, but may be a way to communicate with those around him. So while it may be described as a symptom it can also help parents and others start working with the client. The highest risk factor for a client to be diagnosed with autism is having a sibling with ASD.

What response does the registered nurse (RN) provide to the mother of an 8 month old who is concerned she has spoiled her daughter because the daughter cries every time the mother attempts to leave the hospital room? A) This is a sign that you need to hold her less and help her grow accustomed to being alone B) This could be an indicator of an unhealthy attachment to you that will cause her emotional problems as she grows C) This really is not anything you need to worry about as all babies become spoiled very easily when they feel bad. D) This is a normal occurrence by the time the infant reaches age 6 months and will resolve as she learns that your departure is not permanent.

D. Separation anxiety occurs when infants begin to understand that they are a separate person from their primary caregiver but still have not mastered the concept of object permanence—the idea that something still exists when it is not seen or heard. Thus, when infants are separated from their primary caregiver, they do not understand that the caregiver will return. Because infants do not have a concept of time, they fear that the departure of their parents is permanent. Separation anxiety resolves as children develop a sense of memory. They can keep an image of their parents in mind when the parents are gone and can recall that in the past, the parents returned.