Chapter 33: Alterations in Cognitive and Mental Health

A 17-year-old girl has been diagnosed with bulimia nervosa. Which complication should the nurse carefully assess for in this client? A: Severe erosion of teeth B: Hypertension C: Diabetes mellitus D: Atherosclerosis

ANS: A Rationale: Bulimia refers to recurrent and episodic binge eating and purging by vomiting, accompanied by awareness that the eating pattern is abnormal yet the child is not able to stop the pattern. Adolescents with bulimia may develop severe erosion of their teeth because of the constant exposure to acidic gastrointestinal juices from vomiting. Esophageal tears may also result from forceful vomiting. Hypertension, diabetes mellitus, and atherosclerosis are not associated with bulimia nervosa.

The nurse is caring for a 12-month-old child diagnosed with an autism spectrum disorder. What information from the mother during the health history should the nurse identify as being consistent with the disorder? A: The child speaks in complete sentences. B: The child sleeps at least 12 out of every 24 hours. C: The child responds warmly to the father but not to the mother. D: The child constantly stares at a rotating wheel on the crib mobile.

ANS: D Rationale: A manifestation of an autism spectrum disorder is an abnormal response to sensory stimuli such as staring at a rotating wheel on the crib mobile. A child with an autism spectrum disorder will demonstrate repetitive words and failure to develop social relationships. The number of hours of sleep is not used to help identify an autism spectrum disorder.

After an assessment, the nurse is concerned that a school-age child is at risk for developing a mental health disorder. Which assessment data will the nurse use to develop an appropriate plan care? Select all that apply. A: The parents recently divorced B: The father is unemployed and mother is infrequently home C: The child is learning to play the clarinet in music class in school D: The child is expected to care for younger siblings while mother sleeps E: There is history of multiple injuries obtained from a motor vehicle crash

ANS: A, B, D, E Rationale: 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. Learning to play the clarinet in school has not been associated with an increased risk for mental health disorders in children.

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? A: The child constantly opens and closes the hands. B: The child is highly active and inattentive. C: The child has a slight decrease in head circumference. D: The child has a long face and a prominent jaw.

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

During a routine well-child visit, the mother of a preadolescent patient asks the nurse to explain signs of sexual abuse. The mother is concerned because an older male neighbor has been making comments and overtly admiring the child when playing outdoors. What signs of sexual abuse should the nurse tell the mother to look out for? Select all that apply. A: Child reports abdominal pain. B: Child has a change in school performance. C: Child demonstrates anxiety or trouble sleeping. D: Child does not want to be left alone with a certain adult. E: Child spends a great deal of time with peer-group friends.

ANS: A, B, C, D Rationale: Signs of sexual maltreatment include vague reports of abdominal pain, a change in school performance, anxiety or trouble sleeping, and not wanting to be left alone with a certain adult. Spending time with peer-group friends is an expected preadolescent behavior and is not a sign of sexual maltreatment.

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. A: Hyperthermia B: Orthostatic hypotension C: Weak pulse D: Hypertension E: Hypothermia

ANS: B, C, E Rationale: 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.

The nurse is assessing a 30-month-old child during a routine well-child visit. Which statement by the parent would alert the nurse to further assess for a learning disorder? A: "My child seems to prefer playing with certain toys and will not play with other toys very much." B: "My child likes a certain type of food and does not want to try new foods very often." C: "My child gets restless when we go to a restaurant to eat and we have to wait for our food." D. "My child does not say more than one or two words and grunts to indicate needs."

ANS: D Rationale: Delayed language is often a first sign of an intellectual/learning disorder in a child. The nurse would expect the 30-month-old child to be a picky eater, prefer some toys over others and to be restless when required to sit for an extended period of time.

A child with attention deficit hyperactivity disorder (ADHD) is prescribed methylphenidate hydrochloride. What should the nurse instruct the parents regarding an adverse effect of this medication? A: Anorexia B: Sleepiness C: Garbled speech D: Rapid increase in height

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

An 11-year-old boy has recently been prescribed methylphenidate. The mother calls the pediatrician's office to speak with the advanced practice pediatric nurse practitioner. This mother has been extremely resistant to medication and insists that the medication is not working. How should the nurse respond? A: "Tell me what makes you think the medication is not working" B: "Do you want to try a different medication?" C. "Are you sure you are administering it properly" D. "Do you want to increase the dosage?"

ANS: A Rationale: Asking the mother to explain why she believes the medicine is not working will offer important insights to the mother's definition of effectiveness. It is important for both the mother and the advanced practice pediatric nurse practitioner to develop a shared definition of effectiveness and improvement. Once this is established, the nurse can suggest the next step in the treatment plan. Asking if the mother wants to try a different medication or increase the dosage does not provide any information about the child's response to the current medication. Asking the mother whether she is administering it properly could cause her to take offense and does not provide the necessary information.

The nurse is reviewing the medical record of a child with a mental health disorder and finds that the child is receiving cognitive behavioral therapy. How does the nurse interprets this information? A: Process that requires the individual to view a situation from a different perspective B: Interventions that address family dynamics and family coping C: Individual exploration of the person's conflicts and stressors D: Use of play to explore problems, issues, and conflicts

ANS: A Rationale: Cognitive behavioral therapy helps the individual reframe perceptions, change ideas about a situation, or view a situation from a different perspective. Next, the patient is helped to see the relations among his or her thoughts and beliefs and his or her emotional responses. Finally, the patient is encouraged to use problem solving to identify alternative solutions or ways of behaving. Individual therapy is an interpersonal process in which the patient and care provider together discover, explore, and resolve the patient's perceived and/or actual stressors, conflicts, behavioral responses, doubts, and anxieties. Family therapy focuses on family dynamics. Interventions may be designed to develop family-based coping strategies, such as problem solving or stress management. Play therapy involves the exploration of life's problems, developmental issues, and interpersonal conflicts.

A nurse is teaching the parents of a child diagnosed with attention-deficit/hyperactivity disorder about the condition. The nurse determines that the teaching was successful when the parents make which statements? Select all that apply. A: "We need to set clear limits for our child's behavior." B: "A reward system would be useful to give our child positive feedback." C: "We need to limit the number of choices our child has." D: "We need to give our child all directions at once in case the child gets distracted." E: "If the child acts out, we can explain that this is being bad."

ANS: A, B, C Rationale: The child with ADHD needs clear limits and a limited number of choices to prevent the child from becoming overwhelmed. Positive feedback is essential, such as with a reward or token system. Directions should be broken down into steps that are clear and short. Parents should avoid negative comments that label the child as bad.

The nurse is performing a physical examination of a 5-year-old boy. Which documented findings would most strongly indicate maltreatment of the child? Select all that apply. A: Cuts and bruises on the hands B: Burns on the dorsal surface of the hand C. A curved laceration on the backD. Linear lesions across the chest and abdomen D. Linear lesions across the chest and abdomen E: A bruise on the child's knee D: A scab on the child's elbow

ANS: A, B, C, D Rationale: Several injuries in children clearly signal probable child maltreatment. Children who are maltreated have a higher incidence of hand injury. Children who are beaten with electrical cords, belts, or clotheslines have peculiar circular and linear lesions. Children who are beaten with a belt buckle may have additional curved lacerations from the imprint of the buckle; few other objects produce such contusions. When children burn their hand by accident, they usually burn the palm; burns from maltreatment are often on the dorsal surface. However, it is normal for preschoolers who actively play to have bruises on multiple bony spots (shin, elbows, knees, etc.).

The nurse is caring for a child who has been hospitalized for maltreatment. When reviewing the child's records which findings may have placed the child at an increased risk for abuse? Select all that apply. A: The child's mother has a history of substance use disorder. B: Both parents work outside of the home. C: The child was born prematurely. D: The child has cerebral palsy. E: The child's father is the primary care taker.

ANS: A, C, D Rationale: Although not every child abused or child abuser will fit a profile of characteristics, many will. Child abuse occurs across all socioeconomic levels, but the findings are more prevalent in those experiencing poverty. Additional risk factors include prematurity, chronic illnesses, parental substance use disorder, cerebral palsy and cognitive impairment. Parents working outside the home and paternal caregivers are not families facing increased risk for abuse.

A nurse is assessing a 5-year-old boy and suspects that the child may have an autism spectrum disorder. Which assessments would help support the nurse's suspicions? Select all that apply. A: Inability to make eye contact B: Hypersensitivity to touch C: Lack of facial expression D: Distinct interest in others around him E: Easily distracted from playing

ANS: B, C Rationale: Symptoms associated with autism spectrum disorder include deficits in nonverbal communicative behaviors such as abnormalities in eye contact and lack of facial expression and hyper- or hyposensitivity to sensory input such as touch. In addition, children, and stereotyped or repetitive motor movement, use of object or speech.

An extremely thin preadolescent is being assessed by the nurse. Which clients statement should the nurse identify as being consistent with that of a person with anorexia nervosa? A: "I'd like to grow up to be a model." B: "I'd like to gain weight but just can't." C: "I feel chubby no matter what I wear." D: "I'm afraid that someone is poisoning my food."

ANS: C Rationale: Characteristics of a child with anorexia nervosa include a severely distorted body image with an intense fear of gaining weight or becoming fat. The goal to be a model is not consistent with that of anorexia nervosa. The inability to gain weight is not a characteristic of anorexia nervosa. The fear of food being poisoned is a characteristic of paranoid behavior.

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 suspectsabuse. Which initial action of the nurse is most appropriate? A: Take photographs of the bruises. B: Ask the child to provide a written statement of how he or she got the bruises. C: Document the bruises and any statements made by the child relating to them. D: Interview the child's parents about the origin of the bruises. E: Interview the child's parents about the origin of the bruises.

ANS: C Rationale: 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.

A nurse is assessing a child for the possible obsessive-compulsive disorder. Which question would be most helpful for obtaining information from the child? A. "Are you having any recurring dreams about the trauma you experienced?" B: "Has anything happened at home recently that has upset you?" C: "Is there anything that you do over and over again and can't resist doing?" D: "Do you have times when you wake up during the night without any reason?"

ANS: C Rationale: Obsessive-compulsive disorder is characterized by obsessions--unwanted, unrealistic, irrational recurring or persistent thoughts, impulses, or images beyond excessive worry and compulsions--repetitive behaviors, rituals, or mental acts. Thus, asking the child about doing anything over and over again would be more effective in obtaining additional information. Asking about recurring dreams related to a trauma might be appropriate for assessing posttraumatic stress disorder. Asking about home issues might help to shed light on possible separation anxiety. Asking about waking up at night without a reason provides information about sleep disorders.

For which child's behavior should the nurse identify as being characteristic of separation anxiety disorder? A: An 8-month-old who cries when left with strangers B: A 7-year-old who withdraws from contact with all strangers C: An 8-year-old who will not stay overnight at a friend's house D: A 10-year-old who reports headaches if there is to be a test in school

ANS: C Rationale: Separation anxiety is considered a disorder when an older child shows excessive anxiety about separation or the possibility of separation from parents. They experience acute distress and perhaps frequent nightmares bout separation and, when separated, show symptoms of nausea or vomiting or crying to such a degree it prevents them from visiting at friends' houses. For an 8-month-old, crying when being left with strangers is a normal behavior. A 7-year-old who withdraws from contact with strangers might have been instructed to do this as a form of safety or might be shy. A 10-year-old who reports headaches when a test is scheduled in school is demonstrating some other type of behavior. Separation anxiety would not occur just when a test is scheduled in school.

The nurse is educating the parents of a 6-year-old boy about his learning disorder. Which of the following facts would the nurse integrate into the discussion? A: Learning disorders indicate lower intelligence. B: Learning disorders are synonymous with learning deficits. C: The disorder requires comprehensive special education. D: The disorder is caused by a difference in brain architecture.

ANS: D Rationale: In most cases, the etiology of learning disorders is not known. However, it is believed that the brain architecture is different from that of children without a learning disorder. Children with a learning disability process information differently than children who respond to traditional teaching methods. The "wiring" or architecture of the brain differs from that of a child without a learning disorder, and the biochemical balance may differ as well. Learning disorders do not predict intelligence. They should not be considered deficits but rather different responses to information. Likewise, they can be limited to one area, allowing the child to excel in other areas.

The mother of 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. A: "The cause of autism is largely considered to be related to immunizations administered in infancy." B: "Concerns are often noted as early as 3 to 6 months of age." C: "Once your child begins to speak it will be easier to make a determination." D: "In infancy, a lack of loving behaviors such as cuddling is concerning." E: "Infants who are on the autism spectrum may have difficulty establishing or maintaining eye contact."

ANS: D, E Rationale: 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.