A school-age client diagnosed with autism is admitted to the hospital because of recent vomiting and diarrhea. Which intervention by the nurse is most appropriate upon admission?
Take the child on a tour of the whole unit to familiarize with the surroundings.
Admit the child to a four-bed room to allow interaction with peers.
Orient the child to the hospital room.
Take the child to the playroom immediately to participate in the arts and crafts activity.
The Correct Answer is C
Choice A reason: Taking the child on a tour might be overwhelming and increase anxiety due to the new environment and sensory overload.
Choice B reason: Placing the child in a four-bed room could lead to overstimulation and discomfort due to the presence of multiple unfamiliar people.
Choice C reason: Orienting the child to the hospital room provides a safe and controlled environment, allowing for gradual adjustment to the new setting.
Choice D reason: Immediately taking the child to the playroom for arts and crafts might be too stimulating and could exacerbate stress rather than ease the transition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: This statement is correct; early treatment for clubfoot is essential for the best outcomes.
Choice B reason: The parent's understanding of the need for long-term follow-up care until skeletal maturity is accurate.
Choice C reason: Regular visits for new casts are part of the standard treatment protocol for clubfoot.
Choice D reason: This statement indicates a misunderstanding. Clubfoot treatment typically involves a series of casts changed more frequently than 8-10 weeks apart, not a single spica cast for that duration. Further teaching is needed to correct this misconception.
Correct Answer is B
Explanation
Choice A reason: Acute diarrhea and dehydration are not typical of Hirschsprung disease, which is characterized by bowel obstruction.
Choice B reason: This is the correct choice. Failure to pass meconium within the first 48 hours of life and abdominal distension are classic signs of Hirschsprung disease.
Choice C reason: Projectile vomiting and altered electrolytes could be signs of other conditions but are not specific to Hirschsprung disease.
Choice D reason: Currant jelly-like gelatinous stools and pain are more indicative of intussusception rather than Hirschsprung disease. Hirschsprung disease typically presents with a failure to pass stool and abdominal distension.
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