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 B
Explanation
Choice A reason: Measuring abdominal circumference is not the first action that the nurse should take. This is because abdominal circumference is not a reliable indicator of bowel obstruction or perforation, which are possible complications of meconium ileus. Measuring abdominal circumference may also delay more urgent interventions, such as fluid resuscitation and decompression.
Choice B reason: Gathering supplies for an intravenous (IV) infusion is the first action that the nurse should take. This is because the infant is at risk of dehydration, electrolyte imbalance, and shock due to vomiting and bowel obstruction. The nurse should prepare to administer IV fluids, antibiotics, and blood products as ordered by the healthcare provider.
Choice C reason: Monitoring strict urinary output is not the first action that the nurse should take. This is because urinary output is not the most sensitive indicator of fluid status in infants, especially those with renal insufficiency or oliguria. Monitoring urinary output may also delay more urgent interventions, such as fluid resuscitation and decompression.
Choice D reason: Preparing for anorectal manometry is not the first action that the nurse should take. This is because anorectal manometry is a diagnostic test that measures the pressure and function of the anal and rectal muscles. It is not indicated for infants with suspected meconium ileus, which is a mechanical obstruction of the bowel by thick and sticky meconium. Preparing for anorectal manometry may also delay more urgent interventions, such as fluid resuscitation and decompression.
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.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.