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 social communication and language development.

💙 Receptive language refers to the ability to understand spoken words, directions, and communication from others.

💙 A child with ASD may have delayed understanding of language even when hearing is intact.

💙 Motor development can be relatively typical, while communication and social interaction remain significantly affected.

💙 Children with ASD may also have difficulty interpreting social cues, gestures, facial expressions, and conversational meaning.

💙 Language delays can vary widely, but impaired communication is one of the core diagnostic features of autism spectrum disorder.

💙 The nurse should assess both receptive and expressive language, along with social interaction and repetitive behavior patterns.

💙 Delayed receptive language with otherwise intact hearing and motor development is therefore consistent with autism spectrum disorder.

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Answer 2

Correct Answers

Support systems [ Risk 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 :

Support systems — Risk Factor

❣️ The client has a limited and weakened support system, which increases suicide risk.

❣️ The client recently separated from a partner of 25 years, eliminating an important source of emotional support.

❣️ The client has no immediate family nearby and is estranged from siblings.

❣️ Although the client reports having a few friends, they are reluctant to seek their assistance because they do not want to “burden” them.

❣️ Social isolation can intensify feelings of loneliness and hopelessness during a depressive episode.

❣️ The recent loss of a long-term relationship further increases emotional vulnerability.

❣️ A strong, accessible support network can help a suicidal client obtain assistance during periods of crisis.

❣️ The client's limited perceived social support therefore represents a suicide risk factor.

Physical health — Protective Factor

❣️ The client reports good physical health with no reported morbidities.

❣️ Good physical health reduces the additional psychological burden associated with serious chronic or disabling illness.

❣️ Severe physical illness, chronic pain, and functional impairment can contribute to hopelessness and suicide risk.

❣️ Those additional health-related stressors are not present in this client's history.

❣️ Physical wellness may also support the client's ability to participate actively in mental health treatment.

❣️ The client can potentially engage in therapeutic activities and other healthy coping strategies without major physical limitations.

❣️ This finding does not eliminate the client's substantial psychiatric suicide risk.

❣️ Within the findings provided, good physical health functions as a protective factor.

Access to lethal means — Risk Factor

❣️ The client reports having a large supply of alprazolam, providing access to a potentially harmful means of self-injury.

❣️ The client has specifically considered “taking all of them,” demonstrating a connection between suicidal thoughts and an available method.

❣️ Access to a contemplated method substantially increases concern when assessing suicide risk.

❣️ The client's thoughts have progressed beyond nonspecific distress to consideration of a specific means.

❣️ Immediate safety measures should therefore restrict access to medications or other potential methods of self-harm.

❣️ Medication availability is particularly concerning in the setting of worsening depression and hopelessness.

❣️ Suicide precautions and ongoing assessment are necessary because the client has expressed active self-harm thoughts.

❣️ Access to lethal means is therefore a major suicide risk factor.

Family history — Risk Factor

❣️ The client's mother died by suicide, which represents an important suicide risk factor.

❣️ A family history of suicide is associated with an increased likelihood of suicidal behavior.

❣️ The client also experienced the significant emotional trauma of losing a parent to suicide.

❣️ This history occurs alongside the client's longstanding major depressive disorder and previous suicidal ideation.

❣️ Multiple risk factors can combine to increase overall vulnerability.

❣️ The mother's suicide should therefore be included in a comprehensive suicide risk assessment.

❣️ The nurse should also explore how the client's mother's death has affected the client's coping and perceptions of suicide.

❣️ Family history of suicide is clearly a risk factor in this case.

Mental health support — Protective Factor

❣️ The client has participated in psychotherapy for the past 10 years, demonstrating an established connection with mental health care.

❣️ The therapist recognized the client's deterioration and advised self-admission to the mental health facility.

❣️ The client followed that recommendation, demonstrating willingness to access professional assistance during a crisis.

❣️ Established therapeutic relationships provide opportunities for ongoing assessment, counseling, and crisis intervention.

❣️ The client has also remained compliant with prescribed antidepressant therapy despite reporting reduced effectiveness.

❣️ Continued engagement with treatment can facilitate medication reassessment and development of additional coping strategies.

❣️ Professional mental health support does not remove the client's current suicide risk but provides an important resource for intervention.

❣️ Existing mental health support therefore represents a protective factor.

Feelings of self-worth — Risk Factor

❣️ The statement “I'm not worth that” demonstrates markedly diminished self-worth.

❣️ Negative self-perception is consistent with the client's worsening major depressive disorder.

❣️ Feelings of worthlessness can contribute to the belief that others would be better off without the individual.

❣️ The client also describes hopelessness, loneliness, and sadness, strengthening concern about suicide risk.

❣️ The belief that seeking support would burden friends may further discourage the client from requesting help during a crisis.

❣️ Persistent hopelessness and worthlessness are particularly concerning when accompanied by active thoughts of self-harm.

❣️ These thoughts require continued assessment and therapeutic intervention.

❣️ The client's low feelings of self-worth therefore represent a significant risk factor.

Alcohol consumption — Protective Factor

❣️ The client has a history of alcohol misuse, but reports no alcohol consumption since inpatient rehabilitation 4 years ago.

❣️ Current alcohol misuse could increase suicide risk by reducing inhibition and impairing judgment.

❣️ Continued abstinence removes an important substance-related contributor to impulsive suicidal behavior.

❣️ The client's successful completion of rehabilitation also demonstrates the ability to engage with treatment.

❣️ Four years without alcohol suggests sustained use of healthier approaches to managing the previous substance-use problem.

❣️ Maintaining sobriety is especially important during periods of severe depression and emotional stress.

❣️ The history of alcohol misuse remains clinically relevant and should continue to be assessed.

❣️ Based on the client's current abstinence, alcohol consumption is classified as a protective factor in this scenario.

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Answer 3

Correct Answers:

1.5

Rationale :

✍️ Prescribed dose: 0.75 mg PO twice daily

✍️ Available concentration: 1 mg/mL

✍️ Formula:

Volume = Desired dose ÷ Dose on hand × Quantity

✍️ Volume per dose:

0.75 mg ÷ 1 mg × 1 mL = 0.75 mL

✍️ Total daily volume:

0.75 mL × 2 doses

= 1.5 mL/day

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Answer 4

Correct Answers:

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

Rationale :

✏️ A realistic long-term goal for obsessive-compulsive disorder (OCD) is to gradually decrease the frequency of compulsive behaviors.

✏️ Repeatedly checking locks is a compulsion performed to temporarily relieve anxiety associated with obsessive thoughts or doubt.

✏️ Abruptly preventing the ritual can produce significant anxiety and distress, particularly early in treatment.

✏️ Treatment focuses on helping the client progressively tolerate anxiety without relying on the compulsive behavior.

✏️ Exposure and response prevention (ERP) is an effective behavioral approach in which the client encounters anxiety-provoking situations while resisting the usual ritual.

✏️ Gradually reducing checking behavior provides a realistic, measurable, and achievable treatment goal.

✏️ Successful treatment allows the client to develop healthier coping strategies while gaining greater control over compulsions.

✏️ Progressive reduction of repeated lock checking therefore reflects appropriate long-term management of OCD.

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Answer 5

Correct Answers:

Consistent limit setting

Rationale :

🖊️ Consistent limit setting is an effective intervention for managing the impulsive and aggressive behaviors associated with conduct disorder.

🖊️ Children with conduct disorder may violate rules, disregard the rights of others, and demonstrate aggression or destructive behavior.

🖊️ Clear limits establish specific expectations regarding which behaviors are acceptable and unacceptable.

🖊️ Rules should be simple, realistic, and consistently enforced by all staff members and caregivers.

🖊️ Consequences for inappropriate behavior should be established in advance and applied immediately and predictably.

🖊️ Consistency prevents the child from manipulating differences between caregivers or testing whether established boundaries will change.

🖊️ Positive and appropriate behaviors should also receive praise and reinforcement to encourage healthier behavioral patterns.

🖊️ A structured environment with predictable limits promotes self-control, accountability, and safer interactions with others.

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Answer 6

Correct Answers:

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

Rationale :

🖍️ This response demonstrates therapeutic communication by acknowledging the client’s experience without approving of the harmful behavior.

🖍️ The phrase “Tell me more about that” is open-ended and encourages the client to explore the emotions associated with bingeing and purging.

🖍️ Clients with bulimia nervosa may use binge-purge behaviors as maladaptive strategies for managing distress, anxiety, or feelings of loss of control.

🖍️ Exploring the emotional function of the behavior helps the nurse understand the client’s triggers and coping patterns.

🖍️ The response avoids criticism, confrontation, and judgment, which could increase shame and interfere with communication.

🖍️ Establishing a nonjudgmental therapeutic relationship can help the client discuss behaviors that may otherwise be hidden.

🖍️ Greater awareness of emotional triggers creates opportunities to develop healthier coping strategies for managing distress.

🖍️ Encouraging reflection rather than arguing with the client supports insight and promotes progress toward recovery.

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Answer 7

Correct Answers:

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

Rationale :

📗 Frequent lip smacking and involuntary chewing movements after long-term haloperidol therapy are characteristic of tardive dyskinesia (TD).

📗 Tardive dyskinesia is a potentially persistent extrapyramidal movement disorder associated with prolonged exposure to dopamine-blocking antipsychotics.

📗 Typical manifestations include lip smacking, chewing motions, tongue protrusion, facial grimacing, and involuntary movements of the extremities or trunk.

📗 The nurse should carefully document the abnormal movements and promptly notify the healthcare provider for further evaluation.

📗 An assessment tool such as the Abnormal Involuntary Movement Scale (AIMS) may be used to evaluate the presence and severity of abnormal movements.

📗 The healthcare provider may consider reducing the medication dosage, changing the antipsychotic regimen, or initiating specific treatment for TD.

📗 The nurse should not independently discontinue haloperidol, because abrupt medication changes can contribute to psychiatric destabilization and require provider-directed management.

📗 Early recognition and intervention are important because tardive dyskinesia may become persistent or irreversible, particularly when symptoms progress.

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Answer 8

Correct Answers:

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

Rationale :

⚽ Support groups can provide children and families with education, reassurance, and practical strategies for living with a tic disorder.

⚽ Motor and vocal tics are involuntary or only temporarily suppressible behaviors, rather than intentional actions performed by the child.

⚽ Parents may experience frustration, embarrassment, or anxiety when they do not fully understand the nature of the disorder.

⚽ Connecting families with others who have similar experiences can decrease isolation and stigma.

⚽ Support groups can also help parents learn constructive ways to respond to tics without criticizing or punishing the child.

⚽ The nurse should encourage a supportive environment that promotes the child's self-esteem and social functioning.

⚽ Families can also learn about treatment options, school accommodations, and strategies for managing situations in which tics become more noticeable.

⚽ Providing appropriate family education and psychosocial support helps the child cope with the disorder while reducing family distress.

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Answer 9

Correct Answers:

An intelligence quotient (IQ) of below 70

Rationale :

🌹 An IQ below approximately 70 is strongly associated with significantly impaired intellectual functioning and supports a diagnosis of intellectual disability.

🌹 Diagnosis also requires deficits in adaptive functioning, which affect the individual's ability to meet developmental and sociocultural standards for independence.

🌹 The child's difficulty with communication and activities of daily living already indicates impairment in adaptive functioning.

🌹 Intellectual functioning includes abilities such as reasoning, problem-solving, learning, planning, and judgment.

🌹 Standardized intelligence testing is used as part of the comprehensive assessment of these cognitive abilities.

🌹 Intellectual disability begins during the developmental period, which distinguishes it from cognitive decline acquired later in life.

🌹 Current diagnostic approaches emphasize adaptive functioning, rather than relying on an IQ score alone, when determining severity and support needs.

🌹 In this child, an IQ below 70 combined with significant communication and daily-living deficits provides the strongest evidence supporting intellectual disability.

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Answer 10

Correct Answers:

The client responds to questions with disorganized speech.

Rationale :

🌸 Disorganized speech can occur during an episode of acute mania because thoughts may become rapid, poorly organized, and difficult to follow.

🌸 Clients experiencing mania commonly demonstrate racing thoughts, flight of ideas, pressured speech, and distractibility.

🌸 Rapid changes in thought processes can cause the client's responses to move quickly between loosely connected topics.

🌸 Speech may become excessive, loud, rapid, and difficult for others to interrupt or understand.

🌸 Acute mania is also commonly associated with elevated or irritable mood, increased energy, decreased need for sleep, and increased goal-directed activity.

🌸 Severe manic episodes can cause substantial impairment in judgment, communication, and social functioning.

🌸 The nurse should assess the client's thought processes, speech patterns, behavior, sleep, and potential for unsafe impulsive actions.

🌸 Disorganized speech is therefore the finding that most strongly supports the admitting diagnosis of acute mania from the choices provided.

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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

QLexNursing

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.

Correct Answers

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?

QLexNursing

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.

Correct Answers

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?

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?