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: Instilling benzocaine otic drops regularly is not a recommended practice for preventing or treating otitis media. Benzocaine is a topical anesthetic that can temporarily relieve ear pain, but it does not address the underlying cause of the infection. Moreover, benzocaine can cause allergic reactions, skin irritation, or methemoglobinemia, a condition that reduces the oxygen-carrying capacity of the blood. The nurse should instruct the caregiver to avoid using benzocaine otic drops unless prescribed by a health care provider.
Choice B reason: Avoiding any smoking inside the house is a good practice for preventing otitis media. Smoking can irritate the respiratory tract and impair the function of the cilia, the hair-like structures that help clear mucus and bacteria from the middle ear. Smoking can also increase the risk of respiratory infections, allergies, and asthma, which are associated with otitis media. The nurse should praise the caregiver for avoiding smoking and encourage them to maintain a smoke-free environment for the infant.
Choice C reason: Giving the infant the full course of antibiotics is a necessary practice for treating otitis media. Antibiotics can help eliminate the bacteria that cause the infection and reduce the inflammation and pain in the middle ear. However, antibiotics should be used only when prescribed by a health care provider, and the caregiver should follow the instructions carefully. The nurse should remind the caregiver to give the infant the exact dose of antibiotics at the right time and for the entire duration of the treatment, even if the symptoms improve.
Choice D reason: Scheduling a visit for pneumococcal vaccine is a preventive measure for otitis media. Pneumococcal vaccine can protect the infant from the most common strains of Streptococcus pneumoniae, a bacterium that causes otitis media and other serious infections. The vaccine is recommended for all children under 2 years of age, and it is given in four doses at 2, 4, 6, and 12 to 15 months of age. The nurse should verify the infant's immunization status and advise the caregiver to follow the recommended schedule for the pneumococcal vaccine.
Correct Answer is A
Explanation
Choice A reason: Applying a cool pack to the injection site is a simple and effective way to reduce discomfort after receiving the varicella vaccine. The cool pack can help numb the pain, decrease swelling, and prevent bruising. The nurse should instruct the parent to apply the cool pack for 10 to 15 minutes at a time, several times a day, as needed.
Choice B reason: Any level of fever is not serious and does not need to be reported right away. Fever is a common side effect of the varicella vaccine and usually lasts for 1 to 2 days. Fever is a sign that the body is developing immunity against the chickenpox virus. The nurse should instruct the parent to monitor the child's temperature and give them acetaminophen or ibuprofen to lower the fever, if necessary. The nurse should also advise the parent to call the health care provider if the fever is higher than 102°F (38.9°C) or lasts longer than 3 days.
Choice C reason: Chewable children's aspirin will not help prevent inflammation and may cause serious harm. Aspirin is not recommended for children under 18 years of age who have viral infections, such as chickenpox, because it can increase the risk of Reye's syndrome, a rare but potentially fatal condition that affects the brain and liver. The nurse should instruct the parent to avoid giving the child aspirin or any products that contain aspirin, such as bismuth subsalicylate.
Choice D reason: Keeping the child home from daycare for the next two days is not necessary and may be inconvenient. The varicella vaccine is very effective at preventing chickenpox and does not pose a risk of spreading the virus to others. The nurse should instruct the parent to resume the child's normal activities, unless they have other symptoms that warrant staying home, such as rash, vomiting, or diarrhea.
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