A 7-year-old child without any other diagnosed problems engages in jaw clenching and rocking behaviors. Which condition should the nurse anticipate?
Autism Spectrum Disorder
Stereotypic Movement Disorder
Attention Deficit Hyperactivity Disorder
Intellectual Disability Disorder
The Correct Answer is A
Choice A Reason:
Autism Spectrum Disorder (ASD) is characterized by challenges with social skills, repetitive behaviors, and communication difficulties. Jaw clenching and rocking are forms of self-stimulatory behavior (stimming) often observed in individuals with ASD¹³¹⁴. These behaviors can serve as a coping mechanism to manage sensory overload or express emotions.
Choice B Reason:
Stereotypic Movement Disorder involves repetitive, seemingly purposeless movements. While jaw clenching and rocking could be symptoms, they are more commonly associated with ASD. Stereotypic Movement Disorder is typically diagnosed when these behaviors interfere significantly with normal activities or result in self-harm, which is not mentioned in the child's description.
Choice C Reason:
Attention Deficit Hyperactivity Disorder (ADHD) is marked by an ongoing pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development. The behaviors described, jaw clenching and rocking, are not typical indicators of ADHD, which more commonly includes symptoms like difficulty staying focused, hyperactivity, and impulsive actions.
Choice D Reason:
Intellectual Disability Disorder is characterized by limitations in intellectual functioning and adaptive behavior, which covers a range of everyday social and practical skills. The behaviors of jaw clenching and rocking do not directly indicate Intellectual Disability Disorder. This condition is usually identified by deficits in intellectual and adaptive functioning, not by specific behaviors like those described.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason
Using an antiemetic one hour after administration of methotrexate is not a standard recommendation. Antiemetics are typically used to prevent nausea and vomiting associated with chemotherapy and are taken before or at the time of methotrexate administration, not afterward.
Choice B Reason
Drinking 2-3 liters of water per day is important for patients taking methotrexate to prevent kidney damage by ensuring adequate hydration and facilitating the excretion of the drug¹. Methotrexate can be nephrotoxic, and proper hydration helps to mitigate this risk.
Choice C Reason
Rinsing the mouth with an alcohol-based mouthwash is not recommended for patients taking methotrexate. Alcohol can cause drying and irritation, which might exacerbate any mouth sores caused by methotrexate. Instead, patients should use a gentle, non-alcoholic mouthwash to maintain oral hygiene.
Choice D Reason
Taking methotrexate with an NSAID is not advised without specific medical guidance. NSAIDs can increase the toxicity of methotrexate by displacing it from protein-binding sites and reducing its renal clearance, potentially leading to increased side effects.
Correct Answer is C
Explanation
Choice A Reason
Monitoring for hypoglycemia at 1200 is not optimal because it is well past the peak action time of insulin aspart, which occurs approximately 45–90 minutes after administration. By noon, the insulin's effects are waning, and the risk of hypoglycemia is lower compared to the peak action period.
Choice B Reason
Monitoring at 1000 might still catch the tail end of the peak action time, but it is not the most likely time for hypoglycemia to occur. The nurse could miss the initial signs of hypoglycemia if monitoring starts two hours after administration.
Choice C Reason
0900 is the most appropriate time for the nurse to monitor for hypoglycemia. Insulin aspart has a rapid onset of action, peaking in about 45–90 minutes, and the effects last for 3–5 hours. Monitoring one hour after administration aligns with the start of the peak action time, when hypoglycemia is most likely to occur.
Choice D Reason
Monitoring at 1100 is less ideal because it is nearing the end of the peak action period. While there is still a risk for hypoglycemia, the highest risk would have been earlier, closer to the peak action time.
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