Nursing Care of the Child with a Cognitive or Mental Health Disorder
The nurse is interviewing a depressed 13-year-old girl. During the course of the interview, the girl reveals that her best friend is thinking about committing suicide. How should the nurse respond? 1) Are you the only one that knows? 2) Why do you think she wants to kill herself? 3) Do you know how she is planning to kill herself? 4) ?
"Do you know how she is planning to kill herself?" Explanation: Because the girl is depressed, the nurse suspects that the girl is indirectly talking about herself, not her best friend. When an adolescent raises the issue of suicide, it is important to find out exactly how he or she is envisioning suicide and take measures to prevent an attempted suicide. Therefore, the nurse should ask how the "friend" is contemplating suicide in order to gather this information and open a dialogue to encourage the girl to reveal she is talking about herself. The other questions would not elicit the critical information about the method of suicide.
The nurse is conducting a well-child assessment of a 3-year-old. Which of the following statements by the parents would warrant further investigation? a) "He is very active and keeps very busy" b) "He spends hours repeatedly lining up his cars" c) "He would rather run around than sit on my lap and read a book" d) "He spends a lot of time playing with his little cars"
"He spends hours repeatedly lining up his cars" Correct Explanation: The nurse should pay particular attention to reports of a child spending hours in a repetitive activity, such as lining up cars rather than playing them. Most 3-year-olds are very busy and would rather play than sit on a parent's lap. The other statements are not outside the range of normal and do not warrant further investigation.
Which statement by an adolescent with anorexia nervosa would be most typical of an adolescent with this disorder? a) "I'd like to gain weight but just can't." b) "I'm afraid that someone is poisoning my food." c) "I'd like to grow up to be a model." d) "I feel chubby no matter what I wear."
"I feel chubby no matter what I wear." Correct Explanation: Children with eating disorders tend to think of themselves as overweight. This distorted body image leads them to diet excessively.
The nurse is providing teaching about the potential side effects of lithium for the parents of a girl recently diagnosed with bipolar disorder. Which statement by the parents indicates a need for additional teaching? a) "She may notice an increase in urination" b) "If she loses weight, then we know the medication is working." c) "She will probably tell us that she is hungrier than usual." d) "Tremors and nausea are common side effects."
"If she loses weight, then we know the medication is working." Explanation: Weight gain, not weight loss, is a side effect of the drug. An increased appetite occurs with lithium. Lithium is associated with tremors and nausea. Polyuria occurs with lithium.
A 10-year-old girl with ADHD has been on Ritalin for 6 months. The girl's mother calls and tells the nurse that the medication is ineffective and requests an immediate increase in the child's dosage. What should the nurse say? a) "Let me talk to the doctor about this." b) "Let's wait a few more weeks before we do anything." c) "Let's set up an appointment as soon as possible." d) "What does the teacher say?"
"Let's set up an appointment as soon as possible." Correct Explanation: The nurse plays a vital role in administering medicines and observing and reporting responses. A face-to-face appointment with the family and the doctor or advance practice mental health nurse can help uncover patient and parental factors that may be preventing success. Once it is established that the family is using the medication properly as well as instituting structure within the home, it can be determined if an increased dosage or alternate medicine would be appropriate. Deferring to the doctor will not elicit any information from the mother, and waiting will not address the current concerns. The teacher can only reveal partial information about the effectiveness of the medication, which can be reviewed once other factors have been addressed in a face-to-face visit with the family and patient.
In which of the following mental health interventions is the environment arranged to promote therapeutic goals, such as diminishing aggressive behavior and developing adaptive and social skills? A. Cognitive behavioral therapy B. Play therapy C. Group therapy D. Milieu therapy
D. Milieu therapy In milieu therapy, the environment is arranged to promote therapeutic goals, such as diminishing aggressive behavior and developing adaptive and social skills. The therapeutic environment includes the people, activities, programs, and physical factors involved. The milieu provides a safe and supportive environment for children and adolescents who are acutely ill, highly aggressive, and at high risk for abuse or self-harm.
A 7-year-old child is diagnosed with a learning disability involving reading, writing, and spelling. The nurse identifies this as which of the following? a) Dyslexia b) Dyspraxia c) Dyscalculia d) Dysgraphia
Dyslexia Correct Explanation: Dyslexia is a learning disability that involves reading, writing, and spelling. Dyscalculia is a learning disability that involves mathematics and computation. Dyspraxia is a learning disability that involves problems with manual dexterity and coordination. Dysgraphia is a learning disability that involves problems producing the written word.
The nurse is caring for a 13-year-old girl with a nursing diagnosis of ineffective coping related to inability to deal with life stressors as evidenced by few or no meaningful friendships and low self-esteem. Which intervention would be the priority to promote coping skills? a) Set clear limits on behavior. b) Role model appropriate social and conversation skills. c) Encourage her to discuss her thoughts and feelings. d) Demonstrate unconditional acceptance of the child as a person.
Encourage her to discuss her thoughts and feelings. Explanation: The priority intervention is to encourage her to discuss her thoughts and feelings, as this is an initial step toward learning to deal with them appropriately. The other interventions are appropriate, but the priority intervention is to encourage discussion and obtain information from the child. This way the nurse can develop and refine the interventions based on the child's thoughts and feelings.
A nurse is conducting a physical examination of an adolescent girl with suspected bulimia. Which of the following assessment findings would the nurse expect to note? a) Eroded dental enamel b) Soft sparse body hair c) Dry sallow skin d) Thinning scalp hair
Eroded dental enamel Correct Explanation: The nurse should be sure to carefully assess the mouth and oropharynx for eroded dental enamel, red gums, and inflamed throat from self-induced vomiting. The other findings are typically noted with anorexia nervosa.
The nurse is preparing a plan to educate the parents of a 10-year-old boy with a learning disorder. Which of the following will be part of this plan? a) Explain the child's strengths and weaknesses. b) Encourage parents to give the child personal space. c) Tell parents to check on the child regularly. d) Have parents learn the child's facial expressions.
Explain the child's strengths and weaknesses. Correct Explanation: The nurse will explain the nature of the child's disorder but will also point out the strengths the child possesses as part of the plan. Encouraging parents to provide a personal space for the child is an intervention meant to promote autonomy and responsibility for a child with delayed growth and development. Regularly checking up on the child is a preventive measure to promote safety for a child with a developmental disorder. Learning facial expressions is important when a child has impaired communication skills.
You have been working with an adolescent with an eating disorder for several days. Which of the following is an indication that she is developing trust in you? a) Her saying to you that she'll follow your orders but not those of the nurse on the next shift b) Her saying to you that she trusts you more than anyone else c) Her telling you that she is now ready to eat again d) Her telling you that she is still inducing vomiting after each meal
Her telling you that she is still inducing vomiting after each meal Correct Explanation: An adolescent has to be able to trust an adult before she can share confidences.
The nurse is caring for a 10-year-old recently diagnosed with attention deficit/hyperactivity disorder (ADHD). The nurse would expect to provide teaching regarding which of the following medications? a) Buspirone b) Methylphenidate c) Fluoxetine d) Trazodone
Methylphenidate Correct Explanation: Methylphenidate is a psychostimulant commonly prescribed for ADHD. Trazodone is used to treat depression. Buspirone is used for anxiety. Fluoxetine is used for depression.
The nurse is performing a physical assessment of 16-year-old girl who is cognitively challenged. This client attended her local public elementary school through fifth grade and has since been enrolled at a special education school where she has received social and vocational training. She plans on getting a job in the coming month and on living independently in a few years. The nurse recognizes this client's level of cognitive challenge as which of the following? a) Moderate b) Severe c) Profound d) Mild
Mild Correct Explanation: About 85% of children who are cognitively challenged have an IQ of 50 to 70 and may be referred to as "educable" by a school system. During early years, these children learn social and communication skills and are often not too distinguishable from average infants or toddlers. They continue to learn academic skills up to about a sixth-grade level. As adults, they can usually achieve social and vocational skills adequate for minimum self-support. They're able to live independently but need guidance and assistance when faced with new situations or unusual stress.
The nurse is caring for a 10-year-old girl with an anxiety disorder. During a physical examination, which of the following physical findings would the nurse expect to find? a) Patches of hair loss b) Watery eyes c) Dilated eyes d) Absence of nasal hair
Patches of hair loss Correct Explanation: Patches of hair loss that occur with repetitive hair twisting or pulling are associated with anxiety. Watery, dilated eyes and the absence of nasal hair are often signs of substance abuse.
Which of the following signs is consistent with autistic disorder in a 2-year-old boy? a) Has below-average intellectual function b) Possesses excellent language development c) Performs repetitive activity with toys d) Shows signs of losing attained skills
Performs repetitive activity with toys Correct Explanation: The repetitive behavior pattern with the toys, along with observation of communication and social impairment, would suggest autism. Below-average intellectual function is a sign of mental retardation. Loss of attained skills is a sign of Rett syndrome, which occurs only in girls. The presence of excellent language skills suggests Asperger syndrome.
The nurse is discussing the treatment for a child with attention deficit hyperactivity disorder with a group of school nurses. Which of the following would be an appropriate learning setting for a child with ADHD? a) A classroom with windows facing a playground. b) A classroom with tables and chairs rather than individual desks. c) A classroom with a plan of study that is followed each day. d) A classroom in which children self-select their activities.
A classroom with a plan of study that is followed each day. Correct Explanation: For the child with ADHD the learning situations should be structured so that the child has minimal distractions and a supportive teacher. Special arrangements can be made to provide an educational atmosphere that is supportive for the child without the need for the child to leave the classroom.
Treatment for Personality Disorders
A therapeutic behavior management program Group therapy Social skills training Recreational therapy Participation in special education until discharged
Tell whether the following statement is true or false: For young people 10 to 24 years old in the United States, suicide is the fourth leading cause of death. A. True B. False
A. True For young people 10 to 24 years old in the United States, suicide is the fourth leading cause of death (Eaton et al., 2012). Male adolescents are much more likely to commit suicide than females (Cash & Bridge, 2009); the risk for suicide is the greatest among white males, but rates are rapidly increasing for black males.
Which of the following signs and symptoms suggest that a 5-year-old boy who does not maintain eye contact or speak may be autistic? a) The child constantly opens and closes his hands. b) The child has a long face and prominent jaw. c) The child has a slight decrease in head circumference. d) The child is highly active and inattentive.
The child constantly opens and closes his hands. Correct Explanation: Repetitive motor mannerisms such as constantly opening and closing the hands are a typical behavior pattern for autistic disorder. A high level of activity and inattentiveness are typical symptoms of mental retardation. Decrease in head circumference suggests malnutrition or decelerating brain growth. A long face and prominent jaw are symptoms of fragile X syndrome.
A group of nursing students are reviewing medications used to treat attention deficit/hyperactivity disorder (ADHD). The group demonstrates understanding of the information when they identify which of the following as a nonstimulant norepinephrine reuptake inhibitor? 1) Atomoxetine 2) Methylphenidate 3) Lisdexamfetamine 4) Pemoline
Atomoxetine Explanation: Atomoxetine is a nonstimulant norepinephrine reuptake inhibitor used to treat ADHD. Methylphenidate is a psychostimulant used to treat ADHD. Lisdexamfetamine is a psychostimulant used to treat ADHD. Pemoline is a psychostimulant used to treat ADHD.
Characteristics of Bipolar Disorder
Expansiveness Elation Agitation Hyperexcitability Hyperactivity Increased speed of thought or speech Depression
Which behavior typical of children with autistic disorder requires you to maintain special care to keep them safe? a) A fascination with bright colors b) Insensitivity to pain c) Loss of hearing for high frequencies d) A craving for salt
Insensitivity to pain Correct Explanation: A number of children with autistic disorder demonstrate poor sensation of pain and, thus, bite their hands or bang their heads repeatedly.
Types of Child Abuse?
Physical abuse Sexual abuse Neglect Emotional or psychological abuse
Which of the following characteristics are commonly noted in the child with anorexia nervosa? a) The child is impulsive and inattentive when spoken to. b) The child has rigid study skills and ritualistic behavior. c) The child is inactive and participates in sedentary activites. d) The child has trouble sitting still and is figety.
The child has rigid study skills and ritualistic behavior. Correct Explanation: Anorexic children often are described as successful students who tend to be perfectionists and are always trying to please parents, teachers, and other adults. They may make demands on themselves for cleanliness and order in their environment, or they may engage in rigid schedules for studying and other ritualistic behavior.
As many as 50% of children with autistic spectrum disorder are also cognitively challenged. a) False b) True
True Explanation: As many as 50% of children with autistic spectrum disorder are also cognitively challenged; many have a coexistent mental health diagnoses.
Broad Goals of Individual Therapy?
-Resolving conflicts -Restoring developmentally appropriate functioning -Improving self-understanding Reducing symptoms
The nurse in the well-child clinic observes that a 5-year-old child in the waiting room is having trouble using a crayon to color. During the visit, the same child climbs off the table several times even after the nurse has asked him to stay on the table. Each time the nurse reminds him he says, "Oh, yeah," and happily climbs back up. The nurse suspects that which of the following applies to this child? a) The child is autistic. b) The child has failure to thrive. c) The child has attention deficit hyperactive disorder. d) The child has an addicted caregiver.
The child has attention deficit hyperactive disorder. Correct Explanation: The child with ADHD may have these characteristics: Impulsiveness, easy distractibility, frequent fidgeting or squirming, difficulty sitting still, problems following through on instructions despite being able to understand them, inattentiveness when being spoken to, frequent losing of things, going from one uncompleted activity to another, difficulty taking turns, frequent excessive talking, and engaging in dangerous activities without considering the consequences.
The nurse is assessing a 6-year-old with attention deficit/hyperactivity disorder (ADHD). The nurse observes the boy making repeated clicking noises and notes he has a slight grimace. The nurse recommends the boy receive further evaluation for which of the following? a) Asperger syndrome b) Tourette syndrome c) Autism spectrum disorder d) Anxiety disorder
Tourette syndrome Correct Explanation: Repeated vocal tics such as sniffling, grunting, clicking, or word utterances are associated with Tourette syndrome. The syndrome consists of multiple motor tics and one or more motor tics occurring simultaneously at different times. ADHD and obsessive-compulsive disorder occur in 90% of children with Tourette syndrome. Vocal and motor tics are not typical indicators of Asperger syndrome, anxiety disorder, or autism spectrum disorder.
To feed lunch to a child with autistic disorder, which of the following actions would be most important to take? a) Allow the child to ask questions about the procedure. b) Don't allow him to see the spoon approach his mouth. c) Use a repetitive series of movements. d) Use an authoritarian manner to gain control.
Use a repetitive series of movements. Correct Explanation: Children with autistic disorder typically enjoy repetitive movements or the same action over and over.
The nurse is observing a group of two and three year olds in a play group setting. Which of the following behaviors noted in one of the children indicates to the nurse that the child may be autistic? a) While the other children are eating a snack, the child walks around the room feeling the walls and ignores the caregiver who offers him a snack. b) A child flips the light switch off and on until the caregiver asks her to stop and join the other children in playing. c) A child playing in the kitchen area pretends to pour a glass of milk and repeats this over and over. d) After another child takes a toy, the child cries and stomps his feet.
While the other children are eating a snack, the child walks around the room feeling the walls and ignores the caregiver who offers him a snack. Explanation: autistic children become completely absorbed in strange repetitive behaviors such as spinning an object, flipping an electrical switch on and off, or walking around the room feeling the walls. If these movements are interrupted or if objects in the environment are moved, a violent temper tantrum may result. These tantrums may include self-destructive acts such as hand biting and head banging. Although infants and toddlers normally are self-centered, ritualistic, and prone to displays of temper, autistic children show these characteristics to an extreme degree coupled with an almost total lack of response to other people.
A nurse is conducting a mental status examination with a 5-year-old boy who is playing with trains and blocks of different colors. He repeats the same actions with the trains over and over again throughout the examination. Which of the following questions would be most appropriate? a) Are you having fun now? b) What year is it? c) Why does that red train keep crashing into all of the other trains? d) Do you like playing with trains and blocks?
Why does that red train keep crashing into all of the other trains? Correct Explanation: Asking about the red train is an open-ended question that could help the nurse elicit the fantasies and feelings underlying the boy's play. A 5-year-old may not know what year it is. Questions allowing yes or no answers do not open a dialogue.
The drug most commonly abused by children and adolescents is which of the following? a) Alcohol b) Marijuana c) Ecstasy d) Percocet
Alcohol Correct Explanation: Alcohol abuse occurs when a person ingests a quantity sufficient to cause intoxication. It is also the most commonly abused drug among children and adolescents.
A child with ADHD is placed on methylphenidate (Ritalin) therapy. Which of the following symptoms may children on Ritalin develop? a) Anorexia b) Sleepiness c) Rapid increase in height d) Hypotension
Anorexia Correct Explanation: Ritalin typically causes a loss of appetite. Weighing the child periodically to detect whether this has led to a loss of weight is important.
Attention Deficit and Impulse Control Disorders
Attention-deficit/hyperactivity disorder Conduct disorder Oppositional defiant disorder
Effects of Abuse on the Child
Changed behavior -Extreme efforts to please, -withdrawal, and generalized anxiety Poor school performance -Lack of motivation to achieve -Fear of failure -Higher dependence on teachers -Lower social competence
Factors to Assess in a Mental Status Examination
Interaction with the environment Nutrition Temperament Genetic influences Physical health Developmental status Economic factors Living environment Peer interactions Available resources Spiritual perspective Cultural perspective
Risk Factors Associated With Eating Disorders?
Poor communication with parents Dissatisfaction with appearance or weight Lack of regular meals Use of tobacco Altered family dynamics (entangled relationships) Negative family food-related experiences
The nurse is preparing an education plan to help the family to learn about their child's developmental disorder and its treatment. Which of the following interventions will be part of the plan? a) Linking the family to support groups b) Providing education to build social skills c) Conducting developmental assessments of the child d) Teaching how to plan schedules and routines
Teaching how to plan schedules and routines Correct Explanation: Teaching how to plan schedules and routines would be part of the education plan. Providing education to build social skills, conducting developmental assessments of the child, and linking the family to support groups are all nursing interventions for providing services to the child.
Which of the following would suggest that a 5-year-old boy might have a developmental disorder? a) The child has trouble with r, l, and y sounds. b) The child knows what a dog and a cat sound like. c) The child must be supervised when brushing his teeth. d) The child is not able to follow directions.
The child is not able to follow directions. Correct Explanation: A 5-year-old child should be able to follow simple directions. If he is unable to this, he has not yet achieved a developmental milestone. Brushing his teeth with supervision and knowing cat and dog sounds are normal for this age. Having trouble with r, l, and y sounds is not unusual and may continue until age 7.
Rumination disorder is a poorly understood condition of young children. This refers to a) a habit of eating nonfood substances. b) rechewing undigested food. c) fear of moving objects. d) excessive worrying about friendships.
rechewing undigested food. Correct Explanation: Rumination is the rechewing of undigested food. It occurs primarily in infants.
A child is suspected of having bipolar disorder. Which of the following would the nurse identify if the child was experiencing a manic episode? Select all that apply. a) Decreased sleep b) Pressured speech c) Loss of interest in activity d) Flamboyant behavior e) Decreased energy
• Decreased sleep • Pressured speech • Flamboyant behavior Correct Explanation: Manifestations associated with a manic episode include rapid, pressured speech; increased energy; decreased sleep; flamboyant behavior; and irritability. The child also may demonstrate an increase in risk-taking behaviors, resulting in accidents and sexual promiscuity.
You are meeting with a family that has learned that their 11-year-old daughter has some intellectual disabilities. They tell you that she is having trouble coping with different situations at school. Which of the following is the best response? a) "Coping and adaptation are often affected by intellectual disabilities." b) "Just give her some time, she will learn to adjust." c) "It takes time to learn to cope and adjust, give her some more time." d) "Maybe it would be best if she did not play with those kids at school."
"Coping and adaptation are often affected by intellectual disabilities." Correct Explanation: The child is at increased risk for adjustment disorders because the child's coping strategies are not understood or recognized and his or her range of adaptive strategies may be reduced. Coping, adaptation, and social skills development are greatly dependent on abstract thinking and the ability to generalize from one situation to another. Abstract thinking is impaired in intellectual disability. Children who have intellectual disability are often uncomfortable with unfamiliar surroundings and people. Time is needed to build relationships.
A nurse is caring for a 10-year-old intellectually disabled girl hospitalized for a scheduled cholecystectomy. The girl expresses fear related to her hospitalization and unfamiliar surroundings. How should the nurse respond? a) "Tell me about a typical day at home" b) "Have you talked to your parents about this?" c) "Do you want some art supplies?" d) "Don't worry, you will be going home soon"
"Tell me about a typical day at home" Correct Explanation: An IQ of 35 to 50 is classified as moderate. An IQ of 50 to 70 is classified as mild. An IQ of 20 to 35 is classified as severe, and an IQ less than 20 is considered profound
The mother of a 10-year-old boy with attention deficit hyperactivity disorder (ADHD) contacts the school nurse. She is upset because her son has been made to feel different by his peers because he has to visit the nurse's office for a lunch time dose of medication. The boy is threatening to stop taking his medication. How should the nurse respond? a) "You may want to talk to your physician about an extended release medication" b) "He should ignore the children, he needs this medication" c) "I can have the teacher speak with the other children" d) "Remind him that his schoolwork may deteriorate"
"You may want to talk to your physician about an extended release medication" Correct Explanation: The nurse should encourage the family to explore with their physician the option of one of the newer extended-release or once daily ADHD medications. The other statements are not helpful and do not address the mother's or boy's concerns.
Conducting the Focused Health History
-Ask for child or adolescent's perspective on the problem. Interview parents first, then include parents and siblings in family session. -Focus interviews with children or adolescents on their strengths and weaknesses. -Determine the child's level of functioning within the school, family, and peer group. -Ask questions that are appropriate to the child's developmental level. -Assess the child or adolescent's ability to attend and participate in an interview. -Gather information about the child's physical, emotional, behavioral, and cognitive states from birth to present. -Seek information from other involved professionals.
The nurse is performing the physical examination of a child with bulimia. Which of the following would the nurse identify as supporting this disorder? Select all that apply. a) Pink moist gums b) Eroded dental enamel c) Dry sallow skin d) Bradycardia e) Split fingernails
• Split fingernails • Eroded dental enamel Explanation: The adolescent with bulimia will be of normal weight or slightly overweight. The hands will show calluses on the backs of the knuckles and split fingernails. The mouth and oropharynx will exhibit eroded dental enamel, red gums, and an inflamed throat from self-induced vomiting. Bradycardia and dry sallow skin suggest anorexia.
The 18-month-old toddler has been brought into the pediatrician's office by his parents. Which of the following findings are warning signs that the toddler may be autistic based on what he should be able to do according to his age? Select all that apply. a) The child does not use any words b) The child cannot jump rope c) The child does not speak in short sentences d) The toddler does not exhibit attempts to communicate by pointing to objects e) The parents stated that the toddler has never "babbled"
• The child does not use any words • The toddler does not exhibit attempts to communicate by pointing to objects • The parents stated that the toddler has never "babbled" Correct Explanation: An 18-month-old toddler should have babbled by 12 months. He should be using gestures and using single words to communicate. The use of sentences to communicate and the ability to jump rope would be expected later.
The nurse is preparing a presentation for a local health fair on autism spectrum disorders. Which of the following would the nurse include as part of the presentation? a) Autism cannot be cured. b) Scientific evidence supports the use of complementary therapies. c) Children respond best when the environment is less structured. d) Communication therapies are of little value in treating autism.
Autism cannot be cured. Correct Explanation: There are no medications or treatment available to cure autism. Behavioral and communication therapies are very important in caring for a child with autism. Children with autism spectrum disorder respond very well to highly structured educational environments. To date, complementary and alternative medical therapies have not been scientifically proven to improve autism.
You care for a 12-month-old with autistic disorder. Which of the following descriptions would you expect to elicit from his mother on history-taking? a) He stares at a rotating wheel on his crib mobile. b) He already speaks in complete sentences. c) He sleeps at least 12 out of every 24 hours. d) He responds warmly to his father but not to his mother.
He stares at a rotating wheel on his crib mobile. Explanation: Children with autistic disorder seem fascinated by whirling or spinning toys or objects. They are nonverbal and have difficulty forming close relationships.
The mother of an 8-year-old boy is concerned that her son has attention-deficit/hyperactivity disorder. She describes the symptoms he demonstrates. Which of the following behaviors should the nurse recognize as an example of impulsiveness? a) Constantly fidgeting in his chair and shaking his foot b) Repeating words or phrases spoken by others c) Jumping out of his seat in the middle of class and running to the bathroom without the teacher's permission d) Inability to answer a question posed by his teacher because he was daydreaming
Jumping out of his seat in the middle of class and running to the bathroom without the teacher's permission Correct Explanation: The disorder is characterized by three major behaviors: inattention, impulsiveness, and hyperactivity. Inattention makes children become easily distracted and often may not seem to listen or complete tasks effectively. Impulsiveness causes them to act before they think and therefore to have difficulty with such tasks as awaiting turns. With hyperactivity, children may shift excessively from one activity to another, exhibit excessive or exaggerated muscular activity, such as excessive climbing onto objects, constant fidgeting, or aimless or haphazard running. Repeating words or phrases spoken by others is echolalia and is associated with autistic spectrum disorder.
A mother is telling the school nurse about her concerns regarding her 13-year-old daughter, who complains of headaches. Her grades have dropped, and she is sleeping late and going to bed early every night. The nurse advises the mother that the first priority should be which of the following: a) Schedule an immediate history and physical examination. b) Call for an appointment with a psychologist. c) Discuss the situation with her teacher. d) Ask the school psychologist to do psychometric testing.
Schedule an immediate history and physical examination. Correct Explanation: The first step is to conduct a physical examination to rule out or identify illnesses or physical problems that might cause depression. Once any physical causes have been ruled out, the healthcare team can determine the most appropriate approach to assess the girl's symptoms. (less)
Symptoms of Major Depressive Disorder?
Somatic complaints Decline in academic performance Trouble with peer relationships Change in appetite, weight gain or loss Change in attitude and behaviors at home Oppositional and aggressive behavior Sleeping disorders
The nurse is working with a child diagnosed with encopresis. After a complete medical workup has been done, no organic cause has been found for the disorder. The nurse will anticipate that which of the following will be done next? a) The child will be placed in a foster home. b) The child will be started on methylphenidate (Ritalin). c) The child will be put on a high-calorie, high-protein diet. d) The child will be referred for counseling.
The child will be referred for counseling. Correct Explanation: If no organic causes (e.g., worms, megacolon) exist, encopresis indicates a serious emotional problem and a need for counseling for the child and the family caregivers.
Tenants of Cognitive Behavioral Therapy
Thoughts mediate behavior. Causes assigned to behavior are related to how one perceives and assigns meaning to an event. Changing one's patterns of dysfunctional thoughts (cognitions) and responses helps one cope with the event (Hofmann et al., 2010).
Diagnostic Criteria for Oppositional Defiant Disorder
often loses temper (2) often argues with adults (3) often actively defies or refuses to comply with adults' requests or rules (4) often deliberately annoys people (5) often blames others for his or her mistakes or misbehavior (6) is often touchy or easily annoyed by others (7) is often angry and resentful (8) is often spiteful or vindictive Note: Consider a criterion met only if the behavior occurs more frequently than is typically observed in individuals of comparable age and developmental level
The parents of an adolescent are concerned about his mental health and have brought the adolescent into the physician's office for an evaluation. Which of the following statements by the child's parents indicates that the child may have a mental health disorder? Select all that apply. a) "He has lost 10 pounds over the last 4 months." b) "He used to be a straight-A student and now he's bringing home Cs and Ds." c) "He hangs out with the same kids he always has." d) "He still enjoys playing a lot of baseball." e) "He has started sleeping for only 3 hours each night."
• "He has lost 10 pounds over the last 4 months." • "He used to be a straight-A student and now he's bringing home Cs and Ds." • "He has started sleeping for only 3 hours each night." Correct Explanation: Altered sleep patterns, weight loss, and problems at school are commonly found in children with mental health disorders. There also may be alterations in friendships and changes in extracurricular activity participation.
The child has been diagnosed with a mental health disorder and the child's parents are beginning to incorporate behavior management techniques. Which of the following statements by the child's parent indicates the need for further education? Select all that apply. a) "We're trying to make her accountable and responsible for her own behavior." b) "We tell her when she is doing something well." c) "I am quick to point out the things that she does that make me crazy." d) "I use a higher pitched voice when I communicate with her." e) "We have set some boundaries that are nonnegotiable."
• "I am quick to point out the things that she does that make me crazy." • "I use a higher pitched voice when I communicate with her." Correct Explanation: The parents should use a calm, low-pitched voice when communicating with her. They should ignore inappropriate behaviors. The parents should not argue or bargain with the child about set limits. They should praise the child for accomplishments and help the child see the importance of accountability for her own behavior.
The nurse is obtaining the history of an adolescent female who is suspected of having anorexia nervosa. Which of the following would the nurse expect to find? Select all that apply. a) Diarrhea b) Desire for perfectionism c) Warm hands and feet d) Syncope e) Secondary amenorrhea
• Desire for perfectionism • Syncope • Secondary amenorrhea Correct Explanation: The adolescent with anorexia may have a history of constipation, syncope, secondary amenorrhea, abdominal pain, and periodic episodes of cold hands and feet. In addition, the child's self-concept reveals multiple fears, high need for acceptance, disordered body image, and perfectionism.
The child has been diagnosed with attention deficit hyperactivity disorder (ADHD) and has been prescribed methylphenidate (Ritalin). Which of the following findings are most likely adverse effects related to this type of medication? Select all that apply. a) The child complains that his head hurts at times b) The child has been more irritable since beginning methylphenidate (Ritalin) c) The child has gained weight since beginning methylphenidate (Ritalin) d) The child complains that he has developed abdominal pain e) The child's parents state that he sleeps much longer than he used to
• The child complains that his head hurts at times • The child has been more irritable since beginning methylphenidate (Ritalin) • The child complains that he has developed abdominal pain Explanation: Common side effects related to the use of psychostimulants are: headaches, irritability, and abdominal pain. Children typically exhibit a decreased appetite and may have difficulty with insomnia.
Which of the following is an example of impaired adaptive functioning in a 9-year-old boy with a developmental disorder? a) The child cannot correctly copy a phone number. b) The child cannot correctly copy a sentence. c) The child cannot properly dress herself. d) The child's vision is fine but he is a poor reader.
The child cannot properly dress herself. Correct Explanation: A child with impaired adaptive functioning would not be able to dress himself properly, if at all. The inability to copy a phone number or sentence or to read well reflects learning disorders.
Which of the following signs and symptoms suggest that a 5-year-old boy who does not maintain eye contact or speak may be autistic? a) The child constantly pats his legs. b) The child has a long face and prominent jaw. c) The child has a slight decrease in head circumference. d) The child is highly active and inattentive.
The child constantly pats his legs. Correct Explanation: Repetitive motor mannerisms such as the boy constantly patting his legs are a typical behavior pattern for autistic disorder. A high level of activity and inattentiveness are typical symptoms of mental retardation. A decrease in head circumference suggests malnutrition or decelerating brain growth. A long face and prominent jaw are symptoms of fragile X syndrome.
The nurse is working with school-age children who are having enuresis or encopresis. Which of the following will most likely be the first step in this child's treatment? a) The child will be given a strict daily schedule. b) The child will have a complete physical exam. c) The child will be given medications. d) The child will be taken to a therapist.
The child will have a complete physical exam. Correct Explanation: The child with enuresis or encopresis may have a physiologic or psychological cause and may indicate a need for further exploration and treatment. A complete physical exam and assessment is done first to rule out any physical cause.
When teaching parents of a child with encopresis, which of the following would you stress? a) Not punishing the child for encopresis b) Importance of cleaning the child immediately after an accident occurs c) Need for keeping the child close to bathroom facilities at all times d) Necessity for giving 4 to 6 tablespoons of Kaopectate per day
Not punishing the child for encopresis Correct Explanation: Encopresis (inappropriate soiling of stool) is a symptom of an underlying stress or disease. The child needs therapy to determine the cause.
The nurse is conducting an examination of a boy with Tourette's syndrome. Which of the following would the nurse expect to observe? a) Sudden, rapid stereotypical sounds b) Spinning and hand flapping c) Toe walking d) Lack of eye contact
Sudden, rapid stereotypical sounds Correct Explanation: Sudden, rapid, stereotypical sounds are a hallmark fi ding with Tourette's syndrome. Toe walking and unusual behaviors such as hand-flapping and spinning are indicative of autism spectrum disorder (ASD). Lack of eye contact is associated with ASD but is also noted in children without a mental health disorder.
The nurse is collecting data on an 18-month-old old child with a diagnosis of autism. Which of the following clinical manifestations would likely have been noted in the child with this diagnosis? a) The child smiles when the caregiver shows her a stuffed animal. b) The child does not respond or talk to the nurse when asked simple questions. c) The child cries and runs to the door when the caregiver leaves the room. d) The child sits quietly in the caregivers lap during interview.
The child does not respond or talk to the nurse when asked simple questions. Correct Explanation: Children with autism often have blank expressions and a lack of response to verbal stimulation. They do not develop a smiling response to others nor an interest in being touched or cuddled. In fact, they can react violently to attempts to hold them. They do not show the normal fear of separation from parents that most toddlers exhibit. Often they seem not to notice when family caregivers are present.
After teaching the parents of a child with Tourette syndrome about motor and vocal tics, the nurse determines that the teaching was successful when the parents state which of the following? a) "He can control the tics if he really concentrates on doing so." b) "Drugs are the primary method for controlling the symptoms." c) "Vocal tics are harder to control than the motor tics are." d) "If we get him focused on an activity, the tics will be less pronounced."
"If we get him focused on an activity, the tics will be less pronounced." Explanation: Tics become more noticeable or severe during times of stress and less pronounced when the child is focused on an activity such as watching TV, reading, or playing a video game. The tics are not under voluntary control and either type can be difficult to control. Management is highly individualized and involves psychopharmacology and behavioral therapy.
A 10-year-old girl has been referred for evaluation due to difficulties integrating with her peers at her new school. The counselor believes she is at risk for situational low self-esteem due to problematic relationships with both family members and peers. Which of the following is the best approach? a) Engage the girl in dialogue regarding feelings about self/personal appearance. b) Explore the girl's feelings about changes in her body with the onset of puberty. c) Remind her of the importance of good hygiene for better appearance. d) Introduce the concept of accepting differences to reduce conflict.
Engage the girl in dialogue regarding feelings about self/personal appearance. Correct Explanation: Engaging the child in dialogue about self and personal appearance may reveal self-perceptions and allow discussion of reality versus perception; this enables discussion of methods to address perceived weaknesses and to focus on strengths. Appearance may reflect self-perception, and a comment regarding hygiene might be poorly received. While pubertal changes can be stressful, a 10-year-old girl may not have entered puberty and the question may not be relevant. The concept of accepting differences is secondary to engaging child in dialogue about self and appearance.
The nurse is examining a child with fetal alcohol syndrome (FAS). Which of the following assessment findings would the nurse expect to note? a) Low nasal bridge with short upturned nose b) Macrocephaly c) Clubbing of fingers d) Short filtrum with thick upper lip
Low nasal bridge with short upturned nose Correct Explanation: Typical FAS facial features include a low nasal bridge with short upturned nose, flattened midface, and a long filtrum with narrow upper lip. Microcephaly rather than macrocephaly is associated with FAS. Clubbing of fingers is associated with chronic hypoxia.
An 11-year-old boy has recently been prescribed Ritalin. The mother calls the pediatrician's office to speak with the advance practice pediatric nurse practitioner (APPNP). This mother has been extremely resistant to medication and insists that the medication is not working. How should the nurse respond? a) "Are you sure you are administering it properly?" b) "Tell me why you believe the medication is not working." c) "Do you want to increase the dosage?" d) "Do you want to try a different medication?"
"Tell me why you believe the medication is not working." Correct Explanation: Asking the mother to explain why she believes the medicine is not working will offer important insights into the mother's definition of effectiveness. It is important for both the mother and the advance practice pediatric nurse practitioner (APPNP) 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 working with a group of caregivers of school-age children diagnosed with attention deficit hyperactivity disorder. Which of the following statements would be most appropriate for the nurse to make to this group of caregivers? a) "These children study better with quiet background music such as the radio or a CD." b) "These children function best if given a set of instructions and then left to do the task." c) "A frequent change in routine will be helpful so the child does not get bored." d) "The medications your child is on may cause a decreased appetite."
"The medications your child is on may cause a decreased appetite." Correct Explanation: Learning situations should be structured so that the child has minimal distractions. Structured, consistent guidance from the caregivers is needed. Medication is used for some children and these medications may suppress the appetite and affect the child's growth. The child should be given only one simple instruction at a time. Limiting distractions, using consistency, and offering praise for accomplishments are invaluable.
An advance practice pediatric nurse practitioner (APPNP) is conducting a mental status examination with a 6-year-old girl. Which of the following questions would be most appropriate? a) "Isn't it fun to play with dolls?" b) "Why does your pink doll hit all the other dolls?" c) "What is the name of the president of the United States?" d) "Do you like the doll with pink hair the best or the doll with green hair?"
"Why does your pink doll hit all the other dolls?" Correct Explanation: The nurse is trying to elicit the fantasies and feelings underlying the child's play. Asking an open-ended question is likely to reveal this information. A 6-year-old might know the name of the president but the meaning is ambiguous. The other questions would elicit "yes" or "no" answers.
Tell whether the following statement is true or false: Attention-deficit/hyperactivity disorder (ADHD) is linked to psychosocial factors, not genetic or biologic factors. A. True B. False
B. False ADHD is strongly linked to genetic and biologic factors, but psychosocial factors appear to interact in complex ways with such factors. In biologic parents of children with ADHD, 25% to 33% have ADHD (Cormier, 2008). Dopamine transmitter and receptor genes have been linked to ADHD, and abnormalities of brain structure and function have been noted (Cormier, 2008).
The nurse is caring for a girl with anorexia who has been hospitalized with unstable vital signs and food refusal. The girl requires enteral nutrition. The nurse is alert for which of the complications that signal re-feeding syndrome? a) Bradycardia with ectopy b) Hypothermia and irregular pulse c) Cardiac arrhythmias, confusion, seizures d) Orthostatic hypotension
Cardiac arrhythmias, confusion, seizures Correct Explanation: The nurse should be aware that rapid nutritional replacement in the severely malnourished can lead to refeeding syndrome. Refeeding syndrome is characterized by cardiovascular, hematologic, and neurologic complications such as cardiac arrhythmias, confusion, and seizures. Orthostatic hypotension, hypertension, and irregular and decreased pulses are complications of anorexia but do not characterize refeeding syndrome.
The nurse is collecting data from the caregiver of an 8-year-old child who recently started soiling his underwear each day rather than using the toilet to defecate. This behavior indicates a symptom of which of the following? a) Echolalia b) Encephalopathy c) Encopresis d) Enuresis
Encopresis Correct Explanation: Encopresis is chronic involuntary fecal soiling beyond the age when control is expected (about 3 years of age).
A nurse is observing a 10-year-old boy who is in the waiting room of a pediatrician's office. Another child on the other side of the room removes the lid from a toy box, and the 10-year-old boy screams and then cries briefly. Noticing his shoe laces, he begins laughing and untying them. The nurse recognizes this behavior as an example of which of the following? a) Labile mood b) Catatonia c) Flat affect d) Echolalia
Labile mood Correct Explanation: Children with autistic spectrum disorder are said to have a labile mood (crying occurs suddenly and is followed immediately by giggling or laughing or vice versa). Echolalia (repetition of words or phrases spoken by others) and concrete interpretation are also common findings. Children with schizophrenia experience hallucinations (hear or see people or objects that other people cannot) and may display rambling or illogical speech patterns. They may not be responsive (have a flat affect), may withdraw into themselves so completely they are stuporous (catatonia) or be so extremely suspicious that others want to harm them (paranoia) it is difficult for them to function.
A child with an intellectual disability is evaluated and found to have an intelligence quotient (IQ) of 65. The nurse interprets this as reflecting which category of intellectual disability? a) Mild b) Profound c) Moderate d) Severe
Mild Correct Explanation: Mild intellectual disability involves an IQ from 50 to 70. Moderate intellectual disability involves an IQ from 35 to 50. Severe intellectual disability involves an IQ from 20 to 35. A profound intellectual disability involves an IQ less than 20.
A nurse is caring for a child with intellectual disability. The medical chart indicates an IQ of 37. The nurse understands that the degree of disability is classified as which of the following? a) Mild b) Profound c) Severe d) Moderate
Moderate Correct Explanation: An IQ of 35 to 50 is classified as moderate. An IQ of 50 to 70 is classified as mild. An IQ of 20 to 35 is classified as severe, and an IQ less than 20 is considered profound.
The nurse is caring for a child who has been hospitalized repeatedly at multiple hospitals. There is no clear medical diagnosis and the mother is threatening to leave the hospital against medical advice. The nurse suspects which of the following? a) Anxiety disorder b) Bipolar disorder c) Munchhausen syndrome by proxy d) Sexual abuse
Munchhausen syndrome by proxy Correct Explanation: Repeated hospitalizations that fail to produce a medical diagnosis, transfers to other hospitals, and discharges against medical advice are warning signs of Munchhausen syndrome by proxy.
Steve, a 15-year-old Vietnamese boy, has been referred by his homeroom teacher to the school nurse for evaluation. The teacher is concerned that Steve may be suffering from major depression. Who should be the primary source of information to investigate the concerns about Steve? a) Steve's homeroom teacher b) Steve c) Steve's parents d) Steve's school nurse
Steve Correct Explanation: Steve is the primary historian, and the nurse should first elicit his perspective on the problem to establish a therapeutic alliance. The school nurse might have some input, but his or her contact with Steve may have been minimal. Steve's parents can provide insight and assistance, but they may not be willing to do so because of cultural differences. The teacher will provide a valuable timeline and observations as the individual who referred this case; however, Steve is still the primary historian.
