A nurse is collecting data from a toddler who weighs 20 kg (44 lb) and has a full thickness burn to 10% of this body.
Which of the following findings should the nurse report to the provider?

The correct answer is choiced. Encourage the adolescent to perform incentive spirometry to maintain lung capacity.

Choice A rationale: Avoiding influenza and pneumococcal vaccines for 24 months is not recommended. Vaccinations are crucial for preventing respiratory infections, which can be particularly dangerous for individuals with muscular dystrophy due to their compromised respiratory function.

Choice B rationale: Initiating a referral for chest physiotherapy every 4 hours is excessive and impractical. While chest physiotherapy can be beneficial, it is typically recommended at a frequency that is manageable and tailored to the individual’s needs.

Choice C rationale: Recommending the adolescent use a wheelchair to prevent stress on the lower extremities is not ideal. Encouraging mobility and physical activity as tolerated is important to maintain muscle strength and function for as long as possible.

Choice D rationale: Encouraging the adolescent to perform incentive spirometry to maintain lung capacity is appropriate. Incentive spirometry helps improve lung function and prevent respiratory complications, which are common in individuals with muscular dystrophy.

Choice A rationale

Children with autism spectrum disorder often thrive on routines and predictability. Varying daily routines can be distressing and may lead to increased anxiety.

Choice B rationale

Background noise, such as from a television, can be overstimulating for a child with autism spectrum disorder. It is generally recommended to provide a quiet environment to help the child feel more comfortable and at ease.

Choice C rationale

This is the correct intervention. Children with autism spectrum disorder may have difficulty with social interactions and may become overwhelmed by prolonged or intense interactions. Keeping staff visits brief allows for positive interactions while minimizing potential stress for the child.

Choice D rationale

Placing the child in a semi-private room may expose them to additional stimuli and potential social interactions, which can be overwhelming for a child with an autism spectrum disorder. A private room may provide a quieter and more controlled environment.