Chapter 33 children and adolescents, Chapter 24: Children and Adolescents, Chapter 24: Children and Adolescents, Chapter 26 - Children & Adolescents

8. When group therapy is to be used as a treatment modality, the nurse should suggest placing a 9-year-old in a group that uses: a. play activities exclusively. b. group discussion exclusively. c. talk focused on a specific issue. d. play and talk about the play activity.

ANS: D Group therapy for young children takes the form of play. For elementary school children, therapy combines play and talk about the activity. For adolescents, group therapy involves more talking.

17. The child most likely to receive propranolol (Inderal) to control aggression, deliberate self-injury, and temper tantrums is one diagnosed with: a. Attention deficit hyperactivity disorder ADHD. b. Posttraumatic stress disorder. c. Separation anxiety. d. Autistic disorder ASD.

ANS: D Propranolol is useful for controlling aggression, deliberate self-injury, and temper tantrums of some autistic children. It is not indicated in any of the other disorders.

10. A 4-year-old child cries and screams from the time the parents leave the child at preschool until the child is picked up 4 hours later. The child is calm and relaxed when the parents are present. The parents ask, "What should we do?" What is the nurse's best recommendation? a. "Send a picture of yourself to school to keep with the child." b. "Arrange with the teacher to let the child call home at playtime." c. "Talk with the school about withdrawing the child until maturity increases." d. "Talk with your health care provider about a referral to a mental health clinic."

ANS: D Separation anxiety disorder becomes apparent when the child is separated from the attachment figure. Often, the first time separation occurs is when the child goes to kindergarten or nursery school. Separation anxiety may be based on the child's fear that something will happen to the attachment figure. The child needs professional help.

25. 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.

16. Which child shows behaviors indicative of mental illness? a. 4-year-old who stuttered for 3 weeks after the birth of a sibling b. 9-month-old who does not eat vegetables and likes to be rocked c. 3-month-old who cries after feeding until burped and sucks a thumb d. 3-year-old who is mute, passive toward adults, and twirls while walking

ANS: D Symptoms consistent with an autistic spectrum disorder (ASD) are evident in the correct answer. The behaviors of the other children are within normal ranges.

1. A 5-year-old child moves and talks constantly, is easily distracted, and does not listen to the parents. The child awakens before the parents every morning. The child attended kindergarten, but the teacher could not handle the behavior. What is this child's most likely problem? a. Mental retardation b. Oppositional defiant disorder (ODD) c. Pervasive developmental disorder d. Attention deficit hyperactivity disorder (ADHD)

ANS: D The excessive motion, distractibility, and excessive talkativeness suggest ADHD. Developmental delays would be observed if either a pervasive developmental disorder or mental retardation were present. ODD includes serious violations of the rights of others.

1. 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 client's 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.

9. 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.

23. 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.

3. A 5-year-old child with attention deficit hyperactivity disorder (ADHD) bounces out of a chair in the waiting room, runs across the room, and begins to slap another child. What is the nurse's best action? a. Call for emergency assistance from another staff member. b. Instruct the parents to take the child home immediately. c. Direct this child to stop, and then comfort the other child. d. Take the child into another room with toys to act out feelings.

ANS: D The use of play to express feelings is appropriate; the cognitive and language abilities of the child may require the acting out of feelings if verbal expression is limited. The remaining options provide no outlet for feelings or opportunity to develop coping skills.

What are used to treat ADHD?

CNS stimulants, alpha agonists, atomoxetine, and bupropion

Which of the following is least likely to predispose a child to Tourette's Disorder? a. absence of parental bonding b. family history of the disorder c. abnormalities of brain neurotransmitters d. structural abnormalities of the brain

a.

Which of the following nursing diagnoses would be considered the priority in planning care for the child with autism spectrum disorder? a. Risk for self-mutilation evidenced by banging head against wall b. Impaired social interaction evidenced by unresponsiveness to people c. Impaired verbal communication evidenced by absence of verbal expression d. Disturbed personal identity evidenced by inability to differentiate self from others

a.

What is characterized by the withdrawal of the child into the self and into a fantasy world of his or her own creation?

autism spectrum disorder (ASD)

The child with ADHD has a nursing diagnosis of impaired social interaction. Which of the following nursing interventions are appropriate for this child? select all that apply. a. Socially isolate the child when interactions with others are inappropriate b. set limits with consequences on inappropriate behaviors c. provide rewards for appropriate behaviors d. provide group situations for the child

b, c, d

In an effort to help the child with mild to moderate intellectual disability develop satisfying relationships with others, which of the following nursing interventions is most appropriate? a. interpret the child's behavior for others b. set limits on behavior that is socially inappropriate c. Allow the child to behave spontaneously, for he or she has no concept of right or wrong d. this child is not capable of forming social relationships

b.

Which of the following activities would be most appropriate for the child with ADHD? a. monopoly b. volleyball c. pool d. checkers

b.

Which of the following groups is most commonly used for drug management of the child with ADHD? a. CNS depressants (e.g. diazepam [Valium]) b. CNS stimulants (e.g. methylphenidate [Ritalin]) c. Anticonvulsants (e.g. phenytoin [Dilantin]) d. Major tranquilizers (e.g. haloperidol [Haldol])

b.

Which of the following medications is used to treat Tourette's Disorder? a. Methylphenidate (ritalin) b. Haloperidol (Haldol) c. Imipramine (Tofranil) d. phenytoin (Dilantin)

b.

What are general therapeutic approaches for child and adolescent psychiatric disorders?

behavior therapy, family therapy, group therapies (including music, art, crafts, play, and psycho-education) and psychopharmacology

The nursing history and assessment of an adolescent with a conduct disorder might reveal of the following behaviors except: a. manipulation of others for fulfillment of own desires b. chronic violation of rules C. feelings of guilt associated with the exploitation of others d. inability to form close peer relationships

c

The child with autism spectrum disorder has difficulty with trust. With this in mind, which of the following nursing actions would be the most appropriate? a. Encourage all the staff to hold the child as often as possible, conveying trust through touch b. Assign a different staff member each day so child will learn that everyone can be trusted c. Assign same staff person as often as possible to promote feelings of security and trust d. Avoid eye contact, because this is extremely uncomfortable for the child and may even discourage trust

c.

What disorder is repetitive and persistent pattern of behavior in which the basic rights of others or major age appropriate societal norms or rules are violated?

conduct disorder

Certain family dynamics often predispose adolescents to the development of conduct disorder. Which of the following patterns is thought to be a contributing factor? a. Parents who are overprotective b. Parents who have high expectations for their children c. Parents who consistently set limits on their children's behavior d. parents who are alcohol dependent

d.

What are neurotransmitters that have been implicated in ADHD?

dopamine, norepinephrine, serotonin

What is the essential feature of separation anxiety disorder?

excessive anxiety concerning separation from the home or from those to whom the person is attached

What are common medications used for Tourette's disorder?

haloperidol, pimozide, clonidine, guanfacine, and atypical antipsychotics such as risperidone, olanzapine, and ziprasidone

What are symptoms of ADHD?

inattention or hyperactivity and impulsiveness or a combination of the two

What is defined by deficits in general intellectual functioning and adaptive functioning?

intellectual disability

What is generally accepted about the causes of autism spectrum disorder?

is caused by abnormalities in brain structures or functions. genetic factors are also thought to play a significant role

What are the four levels of intellectual disability?

mild, moderate, severe, and profound

What is characterized by a pattern of negativistic, defiant, disobedient, and hostile behavior toward an authority figures that occurs more frequently than is usually observed in individuals of comparable age and developmental level?

oppositional defiant disorder

Children with separation anxiety disorder may have what?

temperamental characteristics present at birth that predispose them to the disorder

what is the essential feature of tourette's disorder?

the presence of multiple motor tics and one or more vocal tics

True or False: Maternal smoking while pregnant has been linked to hyperactive behavior in offspring

true

True or False: genetic plays a role in the etiology of ADHD

true

14. A child diagnosed with severe autistic spectrum disorder has the nursing diagnosis disturbed personal identity. Which outcome would best address this client diagnosis? 1. The client will name own body parts as separate from others by day five. 2. The client will establish a means of communicating personal needs by discharge. 3. The client will initiate social interactions with caregivers by day four. 4. The client will not harm self or others by discharge.

ANS: 1 Rationale: 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.

6. A nurse assesses an adolescent client diagnosed with conduct disorder who, at the age of 8, was sentenced to juvenile detention. How should the nurse interpret this assessment data? 1. Childhood-onset conduct disorder is more severe than the adolescent-onset type, and these individuals likely develop antisocial personality disorder in adulthood. 2. Childhood-onset conduct disorder is caused by a difficult temperament, and the child is likely to outgrow these behaviors by adulthood. 3. Childhood-onset conduct disorder is diagnosed only when behaviors emerge before the age of 5, and, therefore, improvement is likely. 4. Childhood-onset conduct disorder has no treatment or cure, and children diagnosed with this disorder are likely to develop progressive oppositional defiant disorder.

ANS: 1 Rationale: The nurse should 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

12. When planning care for a client, which medication classification should a nurse recognize as effective in the treatment of Tourette's syndrome? 1. Neuroleptic medications 2. Anti-manic medications 3. Tricyclic antidepressant medications 4. Monoamine oxidase inhibitor medications

ANS: 1 Rationale: The nurse should recognize that neuroleptic (antipsychotic) medications are effective in the treatment of Tourette's syndrome. These medications are used to reduce the severity of tics and are most effective when combined with psychosocial therapy.

5. 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? 1. The pharmacological action of Ritalin causes a decrease in appetite. 2. Hyperactivity seen in ADHD causes increased caloric expenditure. 3. Side effects of Ritalin cause nausea, and, therefore, caloric intake is decreased. 4. Increased ability to concentrate allows the client to focus on activities rather than food.

ANS: 1 Rationale: The pharmacological action of Ritalin causes a decrease in appetite, which often leads to weight loss. Methylphenidate is a central nervous symptom stimulant that serves to increase attention span, control hyperactive behaviors, and improve learning ability.

15. A nursing instructor presents a case study in which a three-year-old child is in constant motion and is unable to sit still during story time. She asks a student to evaluate this child's behavior. Which student response indicates an appropriate evaluation of the situation? 1. "This child's behavior must be evaluated according to developmental norms." 2. "This child has symptoms of attention deficit-hyperactivity disorder." 3. "This child has symptoms of the early stages of autistic disorder." 4. "This child's behavior indicates possible symptoms of oppositional defiant disorder."

ANS: 1 Rationale: The student's evaluation of the situation is appropriate when indicating a need for the client to be evaluated according to developmental norms. The DSM-5 indicates that emotional problems exist if the behavioral manifestations are not age-appropriate, deviate from cultural norms, or create deficits or impairments in adaptive functioning

21. Which of the following risk factors, if noted during a family history assessment, should a nurse associate with the development of IDD? (Select all that apply.) 1. A family history of Tay-Sachs disease 2. Childhood meningococcal infection 3. Deprivation of nurturance and social contact 4. History of maternal multiple motor and verbal tics 5. A diagnosis of maternal major depressive disorder

ANS: 1, 2, 3 Rationale: The nurse should recognize 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 IDD. There are five major predisposing factors of IDD: hereditary factors, early alterations in embryonic development, pregnancy and perinatal factors, medical conditions acquired in infancy or childhood, and environmental influences and other mental disorders.

2. Which nursing intervention related to self-care would be most appropriate for a teenager diagnosed with moderate IDD? 1. Meeting all of the client's self-care needs to avoid injury to the client 2. Providing simple directions and praising client's independent self-care efforts 3. Avoid interfering with the client's self-care efforts in order to promote autonomy 4. Encouraging family to meet the client's self-care needs to promote bonding

ANS: 2 Rationale: Providing simple directions and praise is an appropriate intervention for a teenager diagnosed with moderate IDD. Individuals with moderate mental retardation can perform some activities independently and may be capable of academic skill to a second-grade level.

16. A client has an IQ of 47. Which nursing diagnosis best addresses a client problem associated with this degree of IDD? 1. Risk for injury R/T self-mutilation 2. Altered social interaction R/T non-adherence to social convention 3. Altered verbal communication R/T delusional thinking 4. Social isolation R/T severely decreased gross motor skills

ANS: 2 Rationale: The appropriate nursing diagnosis associated with this degree of IDD is altered social interaction R/T non-adherence to social convention. A client with an IQ of 47 would be diagnosed with moderate intellectual developmental disorder and may also experience some limitations in speech communications.

3. A child has been diagnosed with autistic spectrum disorder. The distraught mother cries out, "I'm such a terrible mother. What did I do to cause this?" Which nursing response is most appropriate? 1. "Researchers really don't know what causes autistic spectrum disorder, but the relationship between autistic disorder and fetal alcohol syndrome is being explored." 2. "Poor parenting doesn't cause autistic spectrum disorder. Research has shown that abnormalities in brain structure or function are to blame. This is beyond your control." 3. "Research has shown that the mother appears to play a greater role in the development of autistic spectrum disorder than the father." 4. "Lack of early infant bonding with the mother has shown to be a cause of autistic spectrum disorder. Did you breastfeed or bottle-feed?"

ANS: 2 Rationale: The most appropriate response by the nurse is to explain to the parent that autistic spectrum disorder is believed to be caused by abnormalities in brain structure or function, not poor parenting. Autism occurs in approximately 11.3 per 1,000 children and is about 4.5 times more likely to occur in boys than girls.

7. Which finding should a nurse expect when assessing a child diagnosed with separation anxiety disorder? 1. The child has a history of antisocial behaviors. 2. The child's mother is diagnosed with an anxiety disorder. 3. The child previously had an extroverted temperament. 4. The child's mother and father have an inconsistent parenting style.

ANS: 2 Rationale: The nurse should expect to find a mother diagnosed with an anxiety disorder when assessing a child 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.

8. A child has been recently diagnosed with mild IDD. What information about this diagnosis should the nurse include when teaching the child's mother? 1. Children with mild IDD need constant supervision. 2. Children with mild IDD develop academic skills up to a sixth-grade level. 3. Children with mild IDD appear different from their peers. 4. Children with mild IDD have significant sensory-motor impairment.

ANS: 2 Rationale: The nurse should inform the child's mother that children with mild IDD develop academic skills up to a sixth-grade level. Individuals with mild IDD are capable of independent living, capable of developing social skills, and have normal psychomotor skills

17. A physician orders methylphenidate (Ritalin) for a child diagnosed with ADHD. Which information about this medication should the nurse provide to the parents? 1. If one dose of Ritalin is missed, double the next dose. 2. Administer Ritalin to the child after breakfast. 3. Administer Ritalin to the child just prior to bedtime. 4. A side effect of Ritalin is decreased ability to learn.

ANS: 2 Rationale: 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.

10. A preschool child is admitted to a psychiatric unit with the diagnosis autistic 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? 1. Encourage and reward peer contact. 2. Provide consistent caregivers. 3. Provide a variety of safe daily activities. 4. Maintain close physical contact throughout the day.

ANS: 2 Rationale: The nurse should provide consistent caregivers as part of the plan of care for a child diagnosed with autistic spectrum disorder. Children diagnosed with autistic spectrum disorder have an inability to trust. Providing consistent caregivers allows the client to develop trust and a sense of security.

13. Which behavioral approach should a nurse use when caring for children diagnosed with disruptive behavior disorders? 1. Involving parents in designing and implementing the treatment process 2. Reinforcing positive actions to encourage repetition of desirable behaviors 3. Providing opportunities to learn appropriate peer interactions 4. Administering psychotropic medications to improve quality of life

ANS: 2 Rationale: The nurse should reinforce positive actions to encourage repetition of desirable behaviors when caring for children diagnosed with disruptive behavior disorder. Behavior therapy is based on the concepts of classical conditioning and operant conditioning.

22. Which of the following findings should a nurse identify that would contribute to a client's development of ADHD? (Select all that apply.) 1. The client's father was a smoker. 2. The client was born 7 weeks premature. 3. The client is lactose intolerant. 4. The client has a sibling diagnosed with ADHD. 5. The client has been diagnosed with dyslexia.

ANS: 2, 4 Rationale: 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.

11. A preschool child diagnosed with autistic spectrum disorder has been engaging in constant head-banging behavior. Which nursing intervention is appropriate? 1. Place client in restraints until the aggression subsides. 2. Sedate the client with neuroleptic medications. 3. Hold client's head steady and apply a helmet. 4. Distract the client with a variety of games and puzzles.

ANS: 3 Rationale: The most appropriate intervention for head banging is to hold the client's head steady and apply a helmet. The helmet is the least restrictive intervention and will serve to protect the client's head from injury.

4. In planning care for a child diagnosed with autistic spectrum disorder, which would be a realistic client outcome? 1. The client will communicate all needs verbally by discharge. 2. The client will participate with peers in a team sport by day four. 3. The client will establish trust with at least one caregiver by day five. 4. The client will perform most self-care tasks independently.

ANS: 3 Rationale: The most realistic client outcome for a child diagnosed with autistic 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.

19. A mother questions the decreased effectiveness of methylphenidate (Ritalin), prescribed for her child's ADHD. Which nursing response best addresses the mother's concern? 1. "The physician will probably switch from Ritalin to a central nervous system stimulant." 2. "The physician may prescribe an antihistamine with the Ritalin to improve effectiveness." 3. "Your child has probably developed a tolerance to Ritalin and may need a higher dosage." 4. "Your child has developed sensitivity to Ritalin and may be exhibiting an allergy."

ANS: 3 Rationale: The nurse should explain to the mother that the child has probably developed a tolerance to Ritalin and may need a higher dosage. Methylphenidate is a central nervous system stimulant, and tolerance can develop rapidly. Physical and psychological dependence can also occur.

18. Which should be the priority nursing intervention when caring for a child diagnosed with conduct disorder? 1. Modify environment to decrease stimulation and provide opportunities for quiet reflection. 2. Convey unconditional acceptance and positive regard. 3. Recognize escalating aggressive behavior and intervene before violence occurs. 4. Provide immediate positive feedback for appropriate behaviors

ANS: 3 Rationale: The priority nursing intervention when caring for a child diagnosed with conduct disorder should be to recognize escalating aggressive behavior and to intervene before violence occurs. This intervention serves to keep the client as well as others safe, which is the priority nursing concern.

20. After studying the DSM-5 criteria for oppositional defiant disorder (ODD), which listed symptom would a student nurse recognize? 1. Arguing and annoying older sibling over the past year 2. Angry and resentful behavior over a three-month period 3. Initiating physical fights for more than 18 months 4. Arguing with authority figures for more than six months

ANS: 4 Rationale: The DSM-5 rules out the diagnosis of ODD when only siblings are involved in argumentative interactions. Angry and resentful behavior over more than six months, not three months, would be considered a symptom of ODD. Initiating physical fights is a symptom of conduct disorder, not ODD. Arguing with authority figures for more than six months is listed by the DSM-5 as a symptom for the diagnosis of ODD.

1. Which developmental characteristic should a nurse identify as typical of a client diagnosed with severe intellectual developmental disorder (IDD)? 1. The client can perform some self-care activities independently. 2. The client has more advanced speech development. 3. Other than possible coordination problems, the client's psychomotor skills are not affected. 4. The client communicates wants and needs by "acting out" behaviors.

ANS: 4 Rationale: The nurse should identify that a client diagnosed with severe IDD may communicate wants and needs by "acting out" behaviors. Severe IDD indicates an IQ between 20 and 34. Individuals diagnosed with severe IDD require complete supervision and have minimal verbal skills and poor psychomotor development.

9. A nursing instructor is teaching about the developmental characteristics of clients diagnosed with moderate intellectual developmental disorder (IDD). Which student statement indicates that further instruction is needed? 1. "These clients can work in a sheltered workshop setting." 2. "These clients can perform some personal care activities." 3. "These clients may have difficulties relating to peers." 4. "These clients can successfully complete elementary school."

ANS: 4 Rationale: The nursing student needs further instruction about moderate IDD, because individuals diagnosed with moderate IDD are capable of academic skill up to a second-grade level. Moderate IDD reflects an IQ range of 35 to 49.

15. 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.

ANS: 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.

5. A child with attention deficit hyperactivity disorder (ADHD) is going to begin medication therapy. The nurse should plan to teach the family about which classification of medications? a. Central nervous system stimulants b. Monoamine oxidase inhibitors (MAOIs) c. Antipsychotic medications d. Anxiolytic medications

ANS: A Central nervous system stimulants increase blood flow to the brain and have proven helpful in reducing hyperactivity in children and adolescents with ADHD. The other medication categories listed would not be appropriate.

6. Shortly after an adolescent's parents announce a plan to divorce, the teen stops participating in sports, sits alone at lunch, and avoids former friends. The adolescent says, "If my parents loved me, then they would work out their problems." What nursing diagnosis is most applicable? a. Ineffective coping b. Decisional conflict c. Chronic low self-esteem d. Disturbed personal identity

ANS: A Ineffective coping is evident in the adolescent's response to family stress and discord. Adolescents value peer interactions, and yet this child has eliminated that source of support. The distracters are not supported by the data in this scenario.

20. An 11-year-old child, who has been diagnosed with oppositional defiant disorder ODD, becomes angry over the rules at a residential treatment program and begins shouting at the nurse. Select the best method to defuse the situation. a. Suggest that the child go to the gym and shoot baskets. b. Administer an antipsychotic medication. c. Place the child in a basket-hold. d. Call a staff member to seclude the child.

ANS: A Redirecting the expression of feelings into nondestructive age-appropriate behaviors such as a physical activity helps the child learn how to modulate the expression of feelings and exert self-control. This method is the least restrictive alternative of those listed and should be tried before resorting to more restrictive measures.

24. A parent with schizophrenia and her 13-year-old child live in a homeless shelter. The child has formed a trusting relationship with a shelter volunteer. The child says, "My three friends and I got an A on our school science project." The nurse can assess that the child: a. displays resiliency. b. has a difficult temperament. c. is at risk for posttraumatic stress disorder. d. uses intellectualization to deal with problems.

ANS: A Resiliency enables a child to handle the stresses of a difficult childhood. Resilient children can adapt to changes in the environment, take advantage of nurturing relationships with adults other than parents, distance themselves from emotional chaos occurring within the family, learn, and use problem-solving skills.

15. Which assessment finding would cause the nurse to consider an 8-year-old child to be most at risk for the development of a psychiatric disorder? a. Being raised by a parent with chronic major depression b. Moving to three new homes over a 2-year period c. Not being promoted to the next grade d. Having an imaginary friend

ANS: A Statistics tell us that children raised by a depressed parent have a 30% to 50% chance of developing an emotional disorder. The chronicity of the parent's depression means it has been a consistent stressor. The other factors do not create ongoing stress.

18. A 12-year-old child has been the neighborhood bully for several years. The parents say, "We can't believe anything our child says." Recently, the child shot a dog with a pellet gun and set fire to a trash bin outside a store. The child's behaviors are most consistent with: a. conduct disorder CD. b. attention deficit ADHD. c. defiance of authority. d. anxiety over separation from a parent.

ANS: A The behaviors mentioned are most consistent with the DSM-IV-TR criteria for CD: aggression against people and animals; destruction of property; deceitfulness; rule violations; and impairment in social, academic, or occupational functioning. The behaviors are not consistent with ADHD and separation anxiety and are more pervasive than defiance of authority.

6. 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 client's 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.

13. 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%.

4. A 16-year-old adolescent with a conduct disorder (CD) has been in a residential program for 3 months. Which outcome should occur before discharge? a. The teen and parents create and consent to a behavioral contract with rules, rewards, and consequences. b. The teen completes an application to enter a military academy for continued structure and discipline. c. The teen is temporarily placed with a foster family until the parents complete a parenting skills class. d. The teen has an absence of anger and frustration for 1 week.

ANS: A The patient and the parents must agree on a behavioral contract that clearly outlines rules, expected behaviors, and consequences for misbehavior. It must also include rewards for following the rules. The patient will continue to experience anger and frustration. The patient and parents must continue with family therapy to work on boundary and communication issues. Separating the patient from the family to work on these issues is not necessary, and separation is detrimental to the healing process.

14. An adolescent is arrested for prostitution and assault on a parent. The adolescent says, "I hate my parents. They focus all their attention on my brother, who's perfect in their eyes." Which nursing diagnosis is most applicable? a. Ineffective coping, related to seeking parental attention as evidenced by acting out b. Disturbed personal identity, related to acting out as evidenced by prostitution c. Impaired parenting, related to showing preference for one child over another d. Hopelessness, related to feeling unloved by parents

ANS: A The patient demonstrates an inability to problem solve by using adaptive behaviors to meet life's demands and roles. The defining characteristics are not present for the other nursing diagnoses. The patient has never mentioned hopelessness, low self-esteem, or disturbed personal identity.

5. 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.

16. 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 student's 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.

26. 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.

27. 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.

21. 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.

9. When assessing a 2-year-old toddler with suspected autistic disorder, a nurse expects: a. hyperactivity and attention deficits. b. failure to develop interpersonal skills. c. history of disobedience and destructive acts. d. high levels of anxiety when separated from a parent.

ANS: B Autistic disorder involves distortions in the development of social skills and language that include perception, motor movement, attention, and reality testing. Caretakers frequently mention the child's failure to develop interpersonal skills. The distracters are more relevant to ADHD, separation anxiety, and CD.

22. 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. "Ritalin's 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.

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

17. 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.

2. A child with attention deficit hyperactivity disorder (ADHD) has hyperactivity, distractibility, and impaired play. The health care provider prescribed methylphenidate (Concerta). The desired behavior for which the nurse should monitor is: a. increased expressiveness in communicating with others b. improved ability to participate in play with other children c. ability to identify anxiety and implement self-control strategies d. improved socialization skills with other children and authority figures

ANS: B The goal is improvement in the child's hyperactivity, distractibility, and play. The remaining options are more relevant for a child with a pervasive developmental or anxiety disorder.

3. A child has been diagnosed with autism spectrum disorder. The distraught mother cries out, "I'm 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?"

ANS: 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.

7. 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.

8. 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.

18. 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.

ANS: 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.

10. 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.

11. 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.

14. 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.

23. A child blurts out answers to questions before the questions are complete, demonstrates an inability to take turns, and persistently interrupts and intrudes in the conversations of others. Assessment data show these behaviors relate primarily to: a. hyperactivity b. impulsivity c. inattention d. defiance

ANS: B These behaviors demonstrate impulsivity. Hyperactive behaviors are more physical in nature, such as running, pushing, and the inability to sit. Inattention is a failure to listen. Defiance is willfully doing what an authority figure has said not to do.

28. The nurse should recognize which of the following findings contribute to a client's development of attention deficit-hyperactivity disorder (ADHD)? Select all that apply. A. The client's 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.

1. What are the primary distinguishing factors between the behavior of children with oppositional defiant disorder (ODD) and those with conduct disorder (CD)? The child with: (select all that apply). a. ODD relives traumatic events by acting them out. b. ODD tests limits and disobeys authority figures. c. ODD has difficulty separating from the parents. d. CD uses stereotypical or repetitive language. e. CD often violates the rights of others.

ANS: B, E Children with ODD are negativistic, disobedient, and defiant toward authority figures without seriously violating the basic rights of others, whereas children with CD frequently behave in ways that violate the rights of others and age-appropriate societal norms. Reliving traumatic events occurs with posttraumatic stress disorder. Stereotypical language behaviors are observed in autistic children. Separation problems with resultant anxiety occur with separation anxiety disorder.

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.

11. A 15-year-old adolescent has run away from home six times. After the adolescent was arrested for prostitution, the parents told the court, "We can't manage our teenager." The adolescent is physically abusive to the mother and defiant with the father. The adolescent's problem is most consistent with criteria for: a. Attention deficit hyperactivity disorder ADHD. b. Childhood depression. c. Conduct disorder CD. d. autism spectrum disorder ASD

ANS: C CDs are manifested by a persistent pattern of behavior in which the rights of others and age-appropriate societal norms are violated. The Diagnostic and Statistical Manual of Mental Disorders (fourth edition, text revision) (DSM-IV-TR) identifies CDs as: serious violations of rules. The patient's clinical manifestations do not coincide with the other disorders listed.

13. An adolescent was arrested for prostitution and assault on a parent. The adolescent says, "I hate my parents. They focus all their attention on my brother, who's perfect in their eyes." Which type of therapy might promote the greatest change in this adolescent's behavior? a. Bibliotherapy b. Play therapy c. Family therapy d. Art therapy

ANS: C Family therapy focuses on problematic family relationships and interactions. The patient has already identified problems within the family.

26. Which behavior indicates that the treatment plan for a child with autism spectrum disorder was effective? The child: a. plays with one toy for 30 minutes. b. repeats words spoken by a parent. c. holds the parent's hand while walking. d. spins around and claps hands while walking.

ANS: C Holding the hand of another person suggests relatedness. Usually, a child with autism would resist holding someone's hand and stand or walk alone, perhaps flapping arms or moving in a stereotypical pattern. The other options reflect behaviors that are consistent with autistic disorder.

21. An adolescent acts out in disruptive ways. When this adolescent threatens to throw a pool ball at another adolescent, which comment by the nurse would set limits? a. "Attention, everyone. We are all going to the craft room." b. "You will be taken to seclusion if you throw that ball." c. "Do not throw the ball. Put it back on the pool table." d. "Please do not lose control of your emotions."

ANS: C Setting limits uses clear, sharp statements about the prohibited behavior and provides guidance for performing a behavior that is expected. The incorrect options represent a threat, use restructuring (which would be inappropriate in this instance), and make a direct appeal to the child's developing self-control that may be ineffective.

12. 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 client's 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 client's head steady and apply a helmet. The helmet is the least restrictive intervention and will serve to protect the client's head from injury.

4. 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.

20. 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 mother's 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.

7. Shortly after a 15-year-old's parents announce a plan to divorce, the adolescent stops participating in sports, sits alone at lunch, and avoids former friends. The adolescent says, "All the other kids have families. If my parents loved me, then they would stay together." Which nursing intervention is most appropriate? a. Develop a plan for activities of daily living. b. Communicate disbelief relative to the adolescent's feelings. c. Assist the adolescent to differentiate reality from perceptions. d. Assess and document the adolescent's level of depression daily.

ANS: C The patient's perceptions that all the other kids are from two-parent households and that he or she is different are not based in reality. Assisting the patient to test the accuracy of the perceptions is helpful.

19. 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.

19. The parent of a child with Tourette's disorder says to the nurse, "I think my child is faking the tics because they come and go." Which response by the nurse is accurate? a. "Perhaps your child was misdiagnosed." b. "Your observation indicates the medication is effective." c. "Tics often change frequency or severity. That doesn't mean they aren't real." d. "This finding is unexpected. How have you been administering your child's medication?"

ANS: C Tics are sudden, rapid, involuntary, repetitive movements or vocalizations characteristic of Tourette's disorder. They often fluctuate in frequency and severity and are reduced or absent during sleep.

22. When a 5-year-old child is disruptive, the nurse says, "You must take a time-out." The expectation is that the child will: a. go to a quiet room until called for the next meal. b. slowly count to 20 before returning to the group activity. c. sit on the edge of the activity until able to regain self-control. d. sit quietly on the lap of a staff member until able to apologize for the behavior.

ANS: C Time-out is designed so that staff can be consistent in their interventions. Time-out may require having the child sit on the periphery of an activity until he or she gains self-control and reviews the episode with a staff member. Time-out may not require having the child go to a designated room and does not involve special attention such as holding. Having the child count to 10 or 20 is not sufficient.

2. A nurse prepares the plan of care for a 15-year-old adolescent with moderate intellectual developmental disorder. What are the highest outcomes that are realistic for this patient? Within 5 years, the patient will: select all that apply. a. Live unaided in an apartment. b. Complete high school or earn a general equivalency diploma (GED). c. Independently perform his or her own personal hygiene. d. Obtain employment in a local sheltered workshop. e. Correctly use public buses to travel in the community.

ANS: C, D, E Individuals with moderate intellectual developmental disorder progress academically to about a second grade level. These people can learn to travel in familiar areas and perform unskilled or semiskilled work. With supervision, they can function in the community, but independent living is not likely.

25. A parent with schizophrenia and 13-year-old child live in a homeless shelter. The child has formed a trusting relationship with a volunteer. The teen says, "I have three good friends at school. We talk and sit together at lunch." What is the nurse's best suggestion to the treatment team? a. Suggest foster home placement. b. Seek assistance from the domestic violence program. c. Make referrals for existing and emerging developmental problems. d. Foster healthy characteristics and existing environmental supports.

ANS: D Because the teenager shows no evidence of poor mental health, the best action would be to foster existing healthy characteristics and environmental supports. No other option is necessary or appropriate under the current circumstances.

12. A 15-year-old adolescent is referred to a residential program after an arrest for theft and running away from home. At the program, the adolescent refuses to participate in scheduled activities and pushes a staff member, causing a fall. Which approach by the nursing staff would be most therapeutic? a. Neutrally permit refusals b. Coax to gain compliance c. Offer rewards in advance d. Establish firm limits

ANS: D Firm limits are necessary to ensure physical safety and emotional security. Limit setting will also protect other patients from the teenager's thoughtless or aggressive behavior. Permitting refusals to participate in the treatment plan, coaxing, and bargaining are strategies that do not help the patient learn to abide by rules or structure.