A nurse is planning care for a school-age child who has autism spectrum disorder. Which of the following actions should the nurse include in the plan?

Explain procedures in detail to the child.

Stay with the child for long periods of time.

Introduce the child to new situations slowly.

Give the child three options when making choices.

Answer and Explanation

The Correct Answer is C

Choice A reason: Explaining procedures in detail to the child can be overwhelming and may not be effective, as children with autism spectrum disorder often have difficulty processing too much verbal information at once.

Choice B reason: Staying with the child for long periods of time is not specific to the care of a child with autism spectrum disorder and does not address their unique needs related to transitions or sensory processing.

Choice C reason: Introducing the child to new situations slowly is important because children with autism spectrum disorder may have difficulty with changes in routine or environment. Gradual introduction can help them adjust and reduce anxiety.

Choice D reason: Giving the child three options when making choices can be helpful, but it is not as critical as introducing new situations slowly. Too many choices can sometimes be overwhelming for children with autism spectrum disorder.

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Correct Answer is B

Explanation

Choice A reason: Producing tears when crying is not typically a sign of severe dehydration. In fact, the ability to produce tears may suggest that the infant is not severely dehydrated.

Choice B reason: A sunken anterior fontanel is a classic sign of severe dehydration in infants. The fontanel, which is the soft spot on the top of a baby's head, can appear sunken when there is significant fluid loss.

Choice C reason: While weight loss can be a sign of dehydration, a 5% weight loss alone does not necessarily indicate severe dehydration. Other clinical signs should also be considered.

Choice D reason: A capillary refill time of 3 seconds is at the upper limit of normal. Prolonged capillary refill time can be a sign of dehydration, but it is not as specific as a sunken anterior fontanel for severe dehydration.

A. An adolescent who has sickle cell anemia and slurred speech. B. A toddler who has a partial-thickness burn on his right hand and requires a dressing change. C. An adolescent who is in skin traction and reports a pain level of 7 on a scale from 0 to 10. D. A toddler who has a new diagnosis of osteomyelitis and is to receive an IV bolus of nafcillin.

Correct Answer is A

Explanation

Choice A reason: Slurred speech may indicate a stroke or other neurological complication, which is a medical emergency. Sickle cell anemia can lead to such complications, and immediate assessment is crucial.

Choice B reason: While a partial-thickness burn requires care, it is not as immediately life-threatening as potential neurological complications. The toddler should be assessed after more urgent cases.

Choice C reason: A pain level of 7 is significant, but pain management can be addressed after more critical needs are met. The adolescent's pain should be managed effectively once urgent cases are stabilized.

Choice D reason: Administering an IV bolus of nafcillin for osteomyelitis is important, but it does not take precedence over potential neurological issues. The toddler should receive the medication promptly after urgent assessments.

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A nurse is planning care for a school-age child who has autism spectrum disorder. Which of the following actions should the nurse include in the plan?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

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