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 D
Explanation
A. "Flat anterior fontanel." A sunken anterior fontanel, not flat, is a sign of severe dehydration in infants.
B. "Dry, hot skin." Dry skin is a symptom of dehydration, but "hot" skin may indicate fever rather than severe dehydration.
C. "Loss of 5% of weight." A 5% weight loss indicates mild dehydration; severe dehydration is characterized by a weight loss of 10% or more.
D. "Absence of tears when crying." Absence of tears is a reliable indicator of severe dehydration in infants.
Correct Answer is ["B","C","D","F"]
Explanation
Findings that require follow-up:
- Edema noted to hands, feet, and periorbital area: Edema in these areas, especially periorbital edema, could indicate fluid retention, possibly from heart failure, kidney issues, or circulatory problems. This should be further evaluated to determine the underlying cause.
- Weak bilateral femoral pulses: Weak femoral pulses could suggest a circulatory problem or arterial insufficiency. This is concerning as it could indicate a vascular or cardiac issue that requires immediate investigation.
- Lower extremities cool to palpation: Cool lower extremities may indicate poor circulation, which can be caused by a cardiovascular issue, such as shock or impaired circulation, which needs immediate attention.
- Blood pressure discrepancy (right arm: 98/60 mm Hg, right leg: 60/40 mm Hg): A significant difference in blood pressure readings between the arms and legs (known as a differential blood pressure) can indicate conditions like coarctation of the aorta (a congenital heart defect), which requires immediate follow-up.
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