The nurse is performing a routine assessment of a 3-year-old at a community health center. Which behavior by the child should alert the nurse to request a follow-up for a possible autism spectrum disorder (ASD)?
Shows indifference to verbal stimulation.
Has a history of temper tantrums.
Strokes the hair of a handheld doll.
Performs odd repetitive behaviors.
The Correct Answer is D
Choice A reason: Showing indifference to verbal stimulation is not a specific sign of ASD. Some children may have hearing problems, language delays, or other developmental issues that affect their response to verbal cues. However, the nurse should still assess the child's hearing and language skills and refer them to a specialist if needed.
Choice B reason: Having a history of temper tantrums is not a specific sign of ASD. Many children have tantrums as a normal part of their emotional development, especially when they are frustrated, tired, or hungry. However, the nurse should still evaluate the frequency, intensity, and duration of the tantrums and provide guidance to the parents on how to manage them.
Choice C reason: Stroking the hair of a handheld doll is not a specific sign of ASD. This behavior may indicate that the child has a preference for tactile stimulation, which is common among children. It may also show that the child has an attachment to the doll, which is a positive sign of social development.
Choice D reason: Performing odd repetitive behaviors is a specific sign of ASD. These behaviors may include rocking, spinning, hand flapping, lining up objects, or repeating words or sounds. These behaviors are often used by children with ASD to cope with sensory overload, anxiety, or boredom. They may also interfere with the child's learning and social interaction. The nurse should request a follow-up for a possible ASD diagnosis and provide support to the child and the parents.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Obtaining a swab of secretions from the penis and urethra is not the appropriate action to take in this situation. This may be done to test for sexually transmitted infections (STIs), such as chlamydia or gonorrhea, that can cause epididymitis, an inflammation of the tube that carries sperm from the testicle. However, epididymitis usually causes gradual pain and swelling, not sudden and severe, and is unlikely to be triggered by a physical activity. Moreover, obtaining a swab may be painful and unnecessary for the adolescent.
Choice B reason: Collecting a sterile urine sample for culture and sensitivity is not the appropriate action to take in this situation. This may be done to test for urinary tract infections (UTIs) or kidney stones that can cause testicular pain. However, UTIs and kidney stones usually cause other symptoms, such as burning or difficulty urinating, blood in the urine, or lower back pain. They are also unlikely to be triggered by a physical activity. Moreover, collecting a urine sample may be difficult and uncomfortable for the adolescent.
Choice C reason: Providing the adolescent with a urinal for urinary hesitancy is not the appropriate action to take in this situation. Urinary hesitancy is the difficulty or delay in starting or maintaining a urine stream. It can be caused by various factors, such as anxiety, medication, prostate problems, or nerve damage. It is not a common symptom of testicular pain and is not related to the cause of the pain. Moreover, providing a urinal may be embarrassing and unnecessary for the adolescent. ⁷
Choice D reason: Reporting the findings immediately to the healthcare provider is the appropriate action to take in this situation. Sudden and severe testicular pain and swelling can be a sign of testicular torsion, a medical emergency that occurs when the testicle twists and cuts off its blood supply. Testicular torsion can be caused by trauma, strenuous exercise, or cold temperature. It can lead to permanent damage or loss of the testicle if not treated promptly. The adolescent needs urgent evaluation and possible surgery to untwist the testicle and restore blood flow.
Correct Answer is B
Explanation
Choice A reason: Enalapril is an angiotensin-converting enzyme (ACE) inhibitor that is used to treat heart failure in infants. It lowers blood pressure and reduces the workload of the heart. Enalapril is not contraindicated in this scenario and does not need to be withheld.
Choice B reason: Digoxin is a cardiac glycoside that is used to treat heart failure and arrhythmias in infants. It increases the contractility of the heart and slows down the heart rate. Digoxin has a narrow therapeutic range and can cause toxicity if the dose is too high or the infant is dehydrated. Digoxin should be withheld if the infant's apical pulse is less than 90 beats/minute, which is the case in this scenario. The nurse should notify the health care provider and monitor the infant for signs of digoxin toxicity, such as nausea, vomiting, bradycardia, and visual disturbances.
Choice C reason: Hydralazine is a vasodilator that is used to treat hypertension and heart failure in infants. It lowers blood pressure and reduces the afterload of the heart. Hydralazine is not contraindicated in this scenario and does not need to be withheld.
Choice D reason: Furosemide is a loop diuretic that is used to treat fluid overload and edema in infants with heart failure. It lowers blood pressure and reduces the preload of the heart. Furosemide is not contraindicated in this scenario and does not need to be withheld
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