The nurse is caring for an autistic child who has been hospitalized. The child rocks continuously. Before the nurse takes any action, what primary piece of data might she want to obtain?

Correct Answer: C

Rationale: Safety is the nurse’s priority. Rocking is a common self-soothing behavior in autism, but if it causes injury (e.g., bruising, head banging), intervention is needed. Duration (A) and consequences (B) are secondary, and functional capacity (D) is important but less immediate than assessing physical harm.

Correct Answer: B

Rationale: Methylphenidate, a stimulant, can suppress appetite and affect growth, making height and weight monitoring critical in children. Oral health (A) isn’t directly related, mood/affect (C) and vital signs (D) may be monitored but are less consistently impacted long-term compared to growth.

Correct Answer: D

Rationale: Risk factors for mental illness in children often include biological factors like low birth weight, genetic predisposition indicated by family history, and environmental stressors such as caregiver neglect. Wealth, while it may influence access to care, is not a direct risk factor for developing mental illness and is thus the exception here.

Correct Answer: B

Rationale: Positive social environments, such as supportive family and peer relationships, are protective factors that reduce the likelihood of developing mental illnesses by fostering resilience and emotional stability. Option B accurately reflects this protective effect.

Correct Answer: A

Rationale: A holistic initial assessment in pediatric mental health includes family dynamics, social context, cultural influences, and psychological status to understand the child’s full situation. Option A is the most comprehensive and aligns with best practices.