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 A
Explanation
Choice A reason: Careful bathing and handling that avoids abdominal manipulation is the best intervention that the nurse can implement during the preoperative period. This is because Wilms' tumor is a rare kidney cancer that mainly affects children and can rupture or spread if touched or pressed. The nurse should avoid any unnecessary pressure on the abdomen and use gentle movements when bathing and handling the infant.
Choice B reason: Administering pain medication based on the FACES pain scale is not the best intervention that the nurse can implement during the preoperative period. This is because the FACES pain scale is a tool that helps children aged 3 and older to communicate their pain level by pointing to a face that matches their pain. However, the infant in this scenario is too young to use this scale and may not be able to express their pain verbally. The nurse should use other methods to assess the infant's pain, such as observing their behavior, vital signs and facial expressions.
Choice C reason: Including the prone position in the every 2 hour turning schedule is not the best intervention that the nurse can implement during the preoperative period. This is because the prone position, which is lying on the stomach, can increase the risk of rupture or spread of the tumor. The nurse should avoid placing the infant in this position and instead use other positions that are comfortable and safe for the infant.
Choice D reason: Giving antiemetic medications to prevent nausea and vomiting is not the best intervention that the nurse can implement during the preoperative period. This is because antiemetic medications are drugs that prevent or treat nausea and vomiting caused by chemotherapy, radiation therapy or surgery. However, the infant in this scenario has not yet undergone any of these treatments and may not have any symptoms of nausea and vomiting. The nurse should only give antiemetic medications if the infant shows signs of nausea and vomiting or if prescribed by the doctor.
Correct Answer is B
Explanation
Choice A reason: Chickenpox is not the most significant illness that may be associated with acute rheumatic fever. Chickenpox is a viral infection that causes an itchy rash and blisters. It is not caused by group A streptococcus (GAS) bacteria, which are the main trigger of acute rheumatic fever.
Choice B reason: Sore throat is the most significant illness that may be associated with acute rheumatic fever. Sore throat can be caused by GAS bacteria, which can also cause strep throat or scarlet fever. If these infections are not properly treated with antibiotics, they can lead to acute rheumatic fever, which is an inflammatory disease that can affect the heart, joints, skin, and brain.
Choice C reason: Mumps is not the most significant illness that may be associated with acute rheumatic fever. Mumps is a viral infection that causes swelling of the salivary glands. It is not caused by GAS bacteria, which are the main trigger of acute rheumatic fever.
Choice D reason: Influenza is not the most significant illness that may be associated with acute rheumatic fever. Influenza is a viral infection that causes fever, cough, sore throat, and muscle aches. It is not caused by GAS bacteria, which are the main trigger of acute rheumatic fever.
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