Question

A nurse is conducting a developmental assessment of a 5-year-old child with a recent diagnosis of autism spectrum disorder. Which of the following findings should the nurse most likely expect?

Answer 1

Correct Answers:

The client demonstrates delayed receptive language skills despite intact hearing and typical motor development.

Rationale :

🧠Children with autism spectrum disorder (ASD) commonly demonstrate difficulties with communication and language development, including understanding spoken language. 🗣️Receptive language delay can occur even when hearing is intact because the difficulty involves processing and understanding communication, rather than an auditory deficit.🤝ASD is characterized by persistent difficulties with social communication and interaction, often accompanied by restricted or repetitive behaviors and interests.

🧩Motor development can remain relatively typical, while significant differences are present in language, social interaction, and communication skills.

📌Core Message

Autism spectrum disorder commonly involves social-communication and language difficulties, including delayed receptive language, even when hearing and motor development are intact.

Answer 2

Correct Answers

Support systems [ Protective Factor ]
Physical health [ Protective Factor ]
Access to lethal means [ Risk Factor ]
Family history [ Risk Factor ]
Mental health support [ Protective Factor ]
Feelings of self-worth [ Risk Factor ]
Alcohol consumption [ Protective Factor ]

Rationale :

🤝The client has friends and an established therapist, providing potential social and professional support, which can protect against suicide risk through connectedness and access to help.

💪The client reports good physical health with no significant medical comorbidities, which is protective because serious or chronic illness can contribute to increased suicide risk.

💊The client has a large supply of alprazolam and has specifically considered taking all of it, demonstrating access to a potentially lethal means and a suicide plan, which substantially increases immediate risk.

🧬The client's mother died by suicide, making family history of suicide an established suicide risk factor.

🧠The client has received psychotherapy for 10 years and maintains contact with a therapist who recognized deterioration and encouraged admission, demonstrating ongoing mental health support and help-seeking.

💔Statements such as “I'm not worth that”, along with hopelessness and loneliness, indicate low self-worth and hopelessness, which increase concern for suicidal behavior.

🍃Although the client has a history of alcohol misuse, they report no alcohol use for 4 years, so their current abstinence from alcohol functions as the protective finding in this assessment; active substance misuse would instead increase risk.

📌Core Message

Major suicide risk factors here include access to lethal medication, family history of suicide, and low self-worth, while social support, good physical health, mental health treatment, and sustained alcohol abstinence provide protective influences.

Answer 3

Correct Answers:

1.5

Rationale :

💊The prescription is 0.75 mg twice daily, giving a total daily dose of 1.5 mg.

🧮The available concentration is 1 mg/mL, so 1.5 mg requires 1.5 mL.

📏The calculation is 1.5 mg ÷ 1 mg/mL = 1.5 mL/day.

🎯Rounded to the nearest tenth, the client receives 1.5 mL daily.

📌Core Message

The client receives 1.5 mg/day, which equals 1.5 mL/day of a 1 mg/mL solution.

Answer 4

Correct Answers:

The client will gradually learn to reduce the number of times that they check their locks.

Rationale :

🔐The repeated checking represents a compulsion performed to reduce anxiety associated with obsessive thoughts.

📉A realistic long-term goal is the gradual reduction of compulsive behavior, rather than demanding abrupt cessation.

🧠Exposure and response prevention (ERP) specifically helps clients gradually face anxiety-provoking situations without performing their usual compulsions.

🌱Gradual reduction promotes improved control of anxiety and functioning while avoiding an unrealistic immediate expectation.

📌Core Message

Effective OCD treatment aims to gradually decrease compulsions and improve the client's ability to tolerate anxiety.

Answer 5

Correct Answers:

Consistent limit setting

Rationale :

🚧Children with conduct disorder can demonstrate aggression, rule violations, and disregard for the rights of others.

📋Consistent limits provide clear behavioral expectations and predictable consequences.

⚖️Consistency reduces opportunities for manipulation and helps the child understand the relationship between behavior and consequences.

🧱Firm, calm boundaries are particularly important when managing impulsive or aggressive behavior.

📌Core Message

Children with conduct disorder benefit from firm, consistent limits and predictable consequences for behavior.

Answer 6

Correct Answers:

"It sounds like purging helps you manage difficult emotions. Tell me more about that."

Rationale :

💬This response uses therapeutic communication by acknowledging the client's perception without approving the harmful behavior.

🫶The statement encourages the client to explore the emotional function of bingeing and purging rather than becoming defensive.

🧠Psychotherapy for eating disorders helps clients identify unhelpful thoughts, develop coping skills, and change maladaptive behavioral patterns.

🌿An open-ended response promotes self-exploration and insight, which supports recovery.

📌Core Message

Therapeutic communication with bulimia should promote exploration of emotions and healthier coping strategies without judgment.

Answer 7

Correct Answers:

Document the findings and contact the healthcare provider to evaluate the need for medication adjustment.

Rationale :

👄Lip smacking and involuntary chewing movements are classic manifestations of tardive dyskinesia.

⏳The risk of tardive dyskinesia increases with long-term exposure to antipsychotic medications such as haloperidol.

📞The nurse should document and promptly notify the provider so the medication regimen can be reassessed.

🩺Treatment changes must be made by the prescriber because withdrawal or adjustment of antipsychotic therapy requires clinical evaluation.

📌Core Message

Lip smacking and chewing movements suggest tardive dyskinesia and require documentation and prompt provider evaluation.

Answer 8

Correct Answers:

Promote involvement in support groups for children and families with tic disorders.

Rationale :

🤝Support groups can connect children and parents with families experiencing similar challenges.

🏡Family education and support can reduce misunderstanding and improve the child's social and emotional environment.

🧠Tics are involuntary or difficult-to-control movements and sounds, rather than intentional misbehavior.

🌈Supportive interventions help families respond appropriately while evidence-based behavioral treatment can be used when tics significantly interfere with functioning.

📌Core Message

Children with tic disorders benefit from a supportive, nonjudgmental environment and access to appropriate family resources.

Answer 9

Correct Answers:

An intelligence quotient (IQ) of below 70

Rationale :

🧠Intellectual disability involves significant limitations in both intellectual functioning and adaptive behavior.

📊An IQ around 70 or below supports evidence of significantly impaired intellectual functioning.

🧩The child's existing difficulty with communication and activities of daily living demonstrates deficits in adaptive functioning.

👦Together, impaired intellectual ability and adaptive functioning strongly support the diagnosis of intellectual disability.

📌Core Message

Intellectual disability requires limitations in intellectual functioning and adaptive behavior, with an IQ around 70 or below supporting the diagnosis.

Answer 10

Correct Answers:

The client responds to questions with disorganized speech.

Rationale :

⚡Acute mania commonly produces rapid thinking and flight of ideas, causing speech to become difficult to follow.

🗣️Speech can become rapid, pressured, and poorly organized as thoughts shift quickly from one topic to another.

🌪️Severe manic episodes can substantially impair thought organization and functioning.

🏥Among the available findings, disorganized speech most strongly supports an acute manic state.

📌Core Message

Acute mania can produce rapid, poorly organized speech and flight of ideas due to accelerated thought processes.

Assessment Findings	Risk Factor	Protective Factor
Support systems
Physical health
Access to lethal means
Family history
Mental health support
Feelings of self-worth
Alcohol consumption

1 :
A nurse is conducting a developmental assessment of a 5-year-old child with a recent diagnosis of autism spectrum disorder. Which of the following findings should the nurse most likely expect?

📌Core Message

2 :
A nurse in a mental health facility is assessing a client.

Correct Answers

📌Core Message

3 :
The healthcare provider prescribes risperidohe 0.75 mg PO twice daily for a client with schizophrenia. The pharmacy dispenses risperidone oral solution, 1 mg/mL. How many mL will the client receive daily? (Round the answer to the nearest tenth.)

📌Core Message

4 :
A hospitalized client with obsessive-compulsive disorder spends excessive time checking if their door is locked. As the nurse develops the plan of care, which of the following would be an appropriate long-term goal?

📌Core Message

5 :
A middle-school age child has been displaying behaviours of conduct disorder. What is an effective nursing intervention for the impulsive and aggressive behaviours that accompany conduct disorder?

📌Core Message

6 :
A client diagnosed with bulimia nervosa states during a group session, "I know I shouldn't binge and purge, but it's the only thing that helps me feel in control." Which of the following responses by the nurse is most appropriate?

📌Core Message

7 :
A nurse is caring for a client with schizophrenia who has been taking haloperidol for several years. During the assessment, the nurse notes the client frequently smacks their lips and makes involuntary chewing motions. Which of the following is the most appropriate nursing action?

📌Core Message

8 :
A nurse is caring for a child diagnosed with a tic disorder. The parents express frustration and concern about the child's frequent vocal and motor tics. Which nursing intervention is appropriate to support the child and family?

📌Core Message

📌Core Message

10 :
A nurse in an acute mental health unit is admitting a client who has bipolar disorder. Which of the following findings supports the admitting diagnosis of acute mania?

📌Core Message

1 : A nurse is conducting a developmental assessment of a 5-year-old child with a recent diagnosis of autism spectrum disorder. Which of the following findings should the nurse most likely expect?

📌Core Message

2 : A nurse in a mental health facility is assessing a client.

Correct Answers

📌Core Message

3 : The healthcare provider prescribes risperidohe 0.75 mg PO twice daily for a client with schizophrenia. The pharmacy dispenses risperidone oral solution, 1 mg/mL. How many mL will the client receive daily? (Round the answer to the nearest tenth.)

📌Core Message

4 : A hospitalized client with obsessive-compulsive disorder spends excessive time checking if their door is locked. As the nurse develops the plan of care, which of the following would be an appropriate long-term goal?

📌Core Message

5 : A middle-school age child has been displaying behaviours of conduct disorder. What is an effective nursing intervention for the impulsive and aggressive behaviours that accompany conduct disorder?

📌Core Message

6 : A client diagnosed with bulimia nervosa states during a group session, "I know I shouldn't binge and purge, but it's the only thing that helps me feel in control." Which of the following responses by the nurse is most appropriate?

📌Core Message

7 : A nurse is caring for a client with schizophrenia who has been taking haloperidol for several years. During the assessment, the nurse notes the client frequently smacks their lips and makes involuntary chewing motions. Which of the following is the most appropriate nursing action?

📌Core Message

8 : A nurse is caring for a child diagnosed with a tic disorder. The parents express frustration and concern about the child's frequent vocal and motor tics. Which nursing intervention is appropriate to support the child and family?

📌Core Message

📌Core Message

10 : A nurse in an acute mental health unit is admitting a client who has bipolar disorder. Which of the following findings supports the admitting diagnosis of acute mania?

📌Core Message

1 :
A nurse is conducting a developmental assessment of a 5-year-old child with a recent diagnosis of autism spectrum disorder. Which of the following findings should the nurse most likely expect?

2 :
A nurse in a mental health facility is assessing a client.

3 :
The healthcare provider prescribes risperidohe 0.75 mg PO twice daily for a client with schizophrenia. The pharmacy dispenses risperidone oral solution, 1 mg/mL. How many mL will the client receive daily? (Round the answer to the nearest tenth.)

4 :
A hospitalized client with obsessive-compulsive disorder spends excessive time checking if their door is locked. As the nurse develops the plan of care, which of the following would be an appropriate long-term goal?

5 :
A middle-school age child has been displaying behaviours of conduct disorder. What is an effective nursing intervention for the impulsive and aggressive behaviours that accompany conduct disorder?

6 :
A client diagnosed with bulimia nervosa states during a group session, "I know I shouldn't binge and purge, but it's the only thing that helps me feel in control." Which of the following responses by the nurse is most appropriate?

7 :
A nurse is caring for a client with schizophrenia who has been taking haloperidol for several years. During the assessment, the nurse notes the client frequently smacks their lips and makes involuntary chewing motions. Which of the following is the most appropriate nursing action?

8 :
A nurse is caring for a child diagnosed with a tic disorder. The parents express frustration and concern about the child's frequent vocal and motor tics. Which nursing intervention is appropriate to support the child and family?

10 :
A nurse in an acute mental health unit is admitting a client who has bipolar disorder. Which of the following findings supports the admitting diagnosis of acute mania?