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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. Arrange an appointment with a pain specialist: A pain specialist can provide comprehensive strategies for managing chronic pain related to fibromyalgia. This includes pharmacologic and non-pharmacologic options tailored to the client's needs.
B. Form an interdisciplinary team for evaluation: While helpful in complex cases, a full team may not be necessary as the first step. It may delay direct pain management support that a pain specialist could initiate more quickly. Interdisciplinary care may follow specialist input.
C. Contact a hospice nurse for an evaluation: Hospice care is intended for clients with terminal illnesses and a life expectancy of six months or less. Fibromyalgia is a chronic, non-fatal condition, so this request indicates a need for pain support, not end-of-life care.
D. Ask for a consultation with a psychologist: A psychologist can help address emotional responses to chronic pain, but cannot directly manage physical symptoms. This should be a supportive measure after physical pain is addressed by a medical pain expert.
Correct Answer is ["A","B","C","D","E"]
Explanation
Rationale:
A. Encourage activity as tolerated: Gradual mobilization supports respiratory function, circulation, and muscle strength after prolonged intubation. Activity also helps reduce the risk of complications like atelectasis and deep vein thrombosis.
B. Assess ability to swallow solids and liquids: After extended intubation, clients are at risk for dysphagia, which can lead to aspiration pneumonia. A swallowing assessment is necessary to ensure safety before resuming a regular oral diet.
C. Assist client with active range of motion: Prolonged immobility in the ICU often leads to deconditioning and muscle weakness. Assisting with range of motion exercises promotes circulation, prevents contractures, and maintains joint flexibility.
D. Reinforce deep breathing exercises: Deep breathing promotes alveolar expansion, improves oxygenation, and prevents postoperative complications such as pneumonia or atelectasis, which are particularly concerning after extubation and in clients with COPD.
E. Obtain dietary consult for meal supplements: Poor appetite post-extubation can contribute to malnutrition and delayed recovery. A dietary consult ensures the client receives adequate caloric and protein intake through appropriate supplements.
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