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: Starting the daughter on birth control pills is not necessary and may interfere with the LHRH treatment. LHRH injections suppress the production of sex hormones and prevent ovulation and menstruation. Birth control pills contain synthetic hormones that may have unwanted side effects and may not be effective in preventing pregnancy in girls with precocious puberty.
Choice B reason: Encouraging the daughter to dress in clothing that suits her sexual maturity level is not advisable and may cause psychological distress. Girls with precocious puberty may feel self-conscious and embarrassed about their early physical development and may face teasing or bullying from their peers. Dressing in clothing that accentuates their sexual maturity may make them feel more uncomfortable and isolated. They should be allowed to dress in clothing that matches their age and emotional development.
Choice C reason: The daughter will not be on this hormone treatment the rest of her life. LHRH injections are usually given until the age of normal puberty, around 11 or 12 years old. Then, the treatment is stopped and the natural puberty process resumes. The injections are meant to delay puberty, not stop it permanently.
Choice D reason: Sexual maturity differences between the daughter and her peers will disappear within a few years is the correct statement that shows understanding of the treatment. LHRH injections slow down the growth and development of the sex organs and secondary sexual characteristics, such as breasts and pubic hair. This allows the girl to grow at a normal rate and reach her full adult height potential. It also reduces the social and emotional problems that may arise from being sexually mature too early. Once the treatment is stopped, the girl will go through puberty at the same time as her peers and the differences will no longer be noticeable.
Correct Answer is D
Explanation
Choice A reason: Playing "peek-a-boo" is a normal behavior for a 6-month-old infant. It shows that the infant has developed object permanence, which is the understanding that objects and people still exist even when they are out of sight. This is a sign of cognitive development and social interaction.
Choice B reason: Turning head to locate sound is a normal behavior for a 6-month-old infant. It shows that the infant has developed auditory localization, which is the ability to identify the direction and distance of a sound source. This is a sign of sensory development and curiosity.
Choice C reason: Having doubled birth weight is a normal milestone for a 6-month-old infant. It shows that the infant has adequate growth and nutrition. The average birth weight for a full-term infant is about 3.4 kg (7.5 lb), and the average weight for a 6-month-old infant is about 6.8 kg (15 lb).
Choice D reason: Demonstrating startle reflex is an abnormal behavior for a 6-month-old infant. The startle reflex, also known as the Moro reflex, is an involuntary response to a sudden loud noise or movement. The infant will extend the arms and legs, arch the back, and then curl the arms and legs inward. This reflex is present at birth and usually disappears by 4 months of age. If the reflex persists beyond 6 months of age, it may indicate a neurological problem or developmental delay. The nurse should request further evaluation by the health care provider.
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