An adolescent with autism spectrum disorder (ASD) comes to the clinic for the first time. Which intervention(s) should the nurse implement? Select all that apply.

Consider having the teen's caregiver wait in the clinic reception area.

Encourage the adolescent to handle the physical exam instruments.

Allow time for talking before beginning the physical assessment.

Familiarize the adolescent with the clinic setting and healthcare staff.

Make every effort to establish eye contact with the adolescent.

Answer and Explanation

Correct Answer : B,C,D

Rationale:
A. Consider having the teen's caregiver wait in the clinic reception area: Adolescents with ASD may experience heightened anxiety in unfamiliar environments. Having their caregiver nearby can offer a sense of security and comfort, making the experience less overwhelming.

B. Encourage the adolescent to handle the physical exam instruments: Allowing the adolescent to touch and explore the equipment before use helps reduce sensory-related anxiety. It also increases cooperation by promoting a sense of predictability and control.

C. Allow time for talking before beginning the physical assessment: Taking time to communicate and build rapport before initiating the assessment helps reduce anxiety and fosters trust. Many adolescents with ASD need more time to process information and adjust to new interactions.

D. Familiarize the adolescent with the clinic setting and healthcare staff: Gradual exposure to the physical space and people helps reduce sensory overload and builds comfort with the environment. Structured familiarity can prevent overstimulation and improve cooperation.

E. Make every effort to establish eye contact with the adolescent: Insisting on eye contact can increase distress, as many individuals with ASD find direct eye contact uncomfortable or overwhelming. Respecting their communication style is more effective than imposing neurotypical expectations.

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

Explanation

Rationale:
A. Any antianxiety medications: Antianxiety medications are not contraindicated with ophthalmic timolol. Unless they directly impact heart rate or blood pressure significantly, they are generally safe to continue in clients with glaucoma using topical beta blockers.

B. Over-the-counter oral antipyretics: Oral antipyretics like acetaminophen are not known to interact adversely with timolol. These medications can be used safely unless otherwise contraindicated for specific patient conditions like liver disease.

C. Nonsteroidal antiinflammatory drugs: NSAIDs such as ibuprofen, when used long-term with beta blockers like timolol or carvedilol, may blunt the antihypertensive effect and increase renal risk, especially in clients on diuretics like spironolactone. This triple combination increases the chance of nephrotoxicity.

D. Other beta-adrenergic blocker agents: Using timolol with systemic beta blockers like carvedilol increases the risk of bradycardia, hypotension, and heart block. Though timolol is topical, systemic absorption can still occur, requiring caution when combining with other beta-blockers.

E. Oral and subcutaneous anticoagulants: There is no direct contraindication between timolol and anticoagulants. Unless the client has bleeding risks associated with other therapies or conditions, concurrent use is generally acceptable.

A. A bucket of water was spilled in the hallway. B. One staff member has not reported to work. C. A client's wife has asked to speak with the charge nurse. D. The census report has not been completed.

Correct Answer is A

Explanation

Rationale:

A. A bucket of water was spilled in the hallway: This represents an immediate safety hazard for staff, clients, and visitors. Wet floors can lead to serious falls and injuries, so it must be addressed first to prevent harm and liability.

B. One staff member has not reported to work: While staffing shortages impact workload and coverage, they do not present an immediate physical danger. This issue can be addressed after eliminating urgent environmental risks.

C. A client's wife has asked to speak with the charge nurse: Family concerns are important and should be acknowledged, but they do not carry the urgency of an environmental safety threat. The nurse can follow up after resolving more pressing issues.

D. The census report has not been completed: Completing paperwork is essential for administrative tracking and planning, but it does not directly impact client safety. It should be prioritized after more urgent clinical and safety concerns are handled.

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An adolescent with autism spectrum disorder (ASD) comes to the clinic for the first time. Which intervention(s) should the nurse implement? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse administers ophthalmic timolol to a client with glaucoma. The client routinely takes carvedilol, spironolactone, and ibuprofen daily. Which medication(s) should the nurse withhold? Select all that apply.

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

Explanation

During shift report, the charge nurse receives notice of several problems. Which problem should the nurse address first?

Correct Answer is A

Explanation

Patient Data Exhibits Choose the most likely options for the information missing from the statement by selecting from the lists of options provided. The client is showing signs of dropdown related to dropdown.

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A client received a thrombolytic medication following a myocardial infarction. When the client has a bowel movement, which action should the nurse implement?

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The nurse is preparing a discharge teaching plan for a client who had a liver transplant. Which instruction is most important to include in this plan?