A nurse is planning care for a newly admitted child who has autism spectrum disorder. Which of the following interventions should the nurse include in the plan?
Establish a reward system for the child.
Limit parent visits with the child.
Keep the door to the child's room open.
Leave a television on during the night.
The Correct Answer is A
A. Establish a reward system for the child. Positive reinforcement encourages desired behaviors and helps manage challenging behaviors.
B. Limit parent visits with the child. Parental presence is comforting for children with autism and helps maintain their routine.
C. Keep the door to the child's room open. A calm and controlled environment is essential; an open door can increase stimuli.
D. Leave a television on during the night. Excess noise or stimuli, especially during rest periods, can increase anxiety in children with autism.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. "Administer the medication on an empty stomach." Phenytoin can be taken with or without food. Administering with food can reduce stomach upset.
B. "Encourage the child to brush their teeth after each meal." Phenytoin increases the risk of gingival hyperplasia, so regular brushing helps maintain oral hygiene and prevents complications.
C. "Crush the child's medication to mix with applesauce." Extended-release capsules should not be crushed as this alters their intended release mechanism.
D. "Observe the child for diarrhea." Diarrhea is not a common side effect of phenytoin. Monitoring should focus on side effects like gingival overgrowth, nystagmus, or skin rashes.
Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}
Explanation
1. Failure to thrive: The infant has poor weight gain despite being hungry after vomiting. Projectile vomiting, as described, often leads to insufficient caloric intake, putting the infant at risk for failure to thrive.
2. Dehydration: Repeated vomiting results in fluid loss, putting the infant at high risk of dehydration, which is common in conditions like pyloric stenosis, suspected here due to the symptoms and palpable abdominal mass.
3. Intussusception typically presents with intermittent, severe abdominal pain, "currant jelly" stools, and sometimes a sausage-shaped mass, which are not noted in this scenario.
4. Meckel diverticulum can cause painless rectal bleeding or obstruction symptoms but is not associated with projectile vomiting or a palpable mass.
5. Hirschsprung disease presents with failure to pass meconium, abdominal distension, and chronic constipation rather than the projectile vomiting seen here.
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