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.

Answer and Explanation

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.

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Correct Answer is ["A","B","C","D"]

Explanation

Findings that require immediate follow-up:

Generalized muscle weakness noted in bilateral lower extremities: This could indicate a neurological or muscular issue, such as Guillain-Barré Syndrome (GBS), which is a concern after a viral infection or vaccination. This requires further investigation and close monitoring for any signs of progression, such as worsening weakness or respiratory involvement.
Child reports pain in legs on palpation, rates pain as 5 on a scale of 0 to 10: This pain could be indicative of muscle cramping or weakness, which may be associated with GBS or another neurological condition. Pain in combination with muscle weakness should be followed up closely.
Abdomen slightly firm, bowel sounds hypoactive, and reports last bowel movement was 3 days ago: This could suggest constipation or a gastrointestinal issue. However, the gastrointestinal symptoms may be secondary to the muscle weakness (if part of a systemic condition like GBS), and should be monitored, but it’s not as urgent as the neurological findings.

Findings that do not require immediate follow-up:

Patellar deep tendon reflexes 1+ bilaterally: A 1+ reflex is on the lower end of normal and does not indicate a severe problem by itself.
Child is awake and alert, responds appropriately to questions: This is a reassuring sign and does not require immediate follow-up.

A. Capillary refill greater than 4 seconds B. Bradycardia C. Tachypnea D. Lethargy

Correct Answer is C

Explanation

A. Capillary refill greater than 4 seconds: This indicates severe hypovolemia, not moderate.
B. Bradycardia: Bradycardia is uncommon in hypovolemia and may occur late as a sign of decompensation, especially in infants.
C. Tachypnea. Tachypnea is a compensatory response to hypovolemia as the body attempts to improve oxygenation and circulation.
D. Lethargy: While lethargy is a concerning sign, it is associated with more severe dehydration than moderate hypovolemia.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["A","B","C","D"]

Explanation

A nurse is caring for a 6-month-old infant who has acute vomiting and diarrhea. Which of the following manifestations should the nurse identify as an indication of moderate hypovolemia?

Correct Answer is C

Explanation

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