A 7-year-old child without any other diagnosed problems engages in jaw clenching and rocking behaviors. Which condition should the nurse anticipate?

Autism Spectrum Disorder

Stereotypic Movement Disorder

Attention Deficit Hyperactivity Disorder

Intellectual Disability Disorder

Answer and Explanation

The Correct Answer is A

Choice A Reason:
Autism Spectrum Disorder (ASD) is characterized by challenges with social skills, repetitive behaviors, and communication difficulties. Jaw clenching and rocking are forms of self-stimulatory behavior (stimming) often observed in individuals with ASD¹³¹⁴. These behaviors can serve as a coping mechanism to manage sensory overload or express emotions.

Choice B Reason:
Stereotypic Movement Disorder involves repetitive, seemingly purposeless movements. While jaw clenching and rocking could be symptoms, they are more commonly associated with ASD. Stereotypic Movement Disorder is typically diagnosed when these behaviors interfere significantly with normal activities or result in self-harm, which is not mentioned in the child's description.

Choice C Reason:
Attention Deficit Hyperactivity Disorder (ADHD) is marked by an ongoing pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development. The behaviors described, jaw clenching and rocking, are not typical indicators of ADHD, which more commonly includes symptoms like difficulty staying focused, hyperactivity, and impulsive actions.

Choice D Reason:
Intellectual Disability Disorder is characterized by limitations in intellectual functioning and adaptive behavior, which covers a range of everyday social and practical skills. The behaviors of jaw clenching and rocking do not directly indicate Intellectual Disability Disorder. This condition is usually identified by deficits in intellectual and adaptive functioning, not by specific behaviors like those described.

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Free Nursing Study Resources

Correct Answer is D

Explanation

Choice a reason:
For individuals with Crohn's disease, eating three large meals may not be the best approach as it can overwhelm the digestive system. Smaller, more frequent meals are often recommended to ease the digestion process and better manage symptoms.

Choice b reason:
Drinking water during meals can help with digestion, but there is no specific requirement to limit it to ten ounces. Adequate hydration is important, but the amount should be tailored to individual needs and tolerances.

Choice c reason:
Choosing coffee over cola is not necessarily beneficial for Crohn's disease management. Both beverages can potentially irritate the gastrointestinal tract, and individuals with Crohn's disease are often advised to limit caffeine and carbonated drinks.

Choice d reason:
Increasing protein intake can be beneficial for clients with Crohn's disease, especially if they have experienced weight loss or malnutrition due to their condition. Protein is essential for healing and repair of tissues, and maintaining adequate protein levels is important for overall health.

A. Administering an antiemetic B. Applying sequential compression devices C. Assessing vital signs D. Hanging the Lactated Ringers solution

Correct Answer is C

Explanation

Choice A reason:
Administering an antiemetic is an important intervention in the PACU, especially if the patient is experiencing nausea or has a history of postoperative nausea and vomiting (PONV). However, it is not the first priority. Antiemetics work by blocking the neurotransmitters that trigger the vomiting reflex. Medications such as ondansetron or promethazine may be used.

Choice B reason:
Applying sequential compression devices is a preventive measure against deep vein thrombosis (DVT), which is a risk due to immobility after surgery. These devices help improve venous return from the lower limbs by applying intermittent pressure. While important, this intervention follows after the assessment of vital signs.

Choice C reason:
Assessing vital signs is the first and foremost priority when a patient is transferred to the PACU. Vital signs, including blood pressure, heart rate, respiratory rate, and oxygen saturation, provide immediate information about the patient's hemodynamic status and can indicate the need for urgent interventions. Any evidence of respiratory or circulatory compromise requires immediate attention.

Choice D reason:
Hanging the Lactated Ringers solution is part of managing the patient's fluid status postoperatively. Lactated Ringers is an isotonic solution that helps to replace lost fluids and maintain electrolyte balance. While important for patient care, it is not the initial priority upon arrival in the PACU.

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A 7-year-old child without any other diagnosed problems engages in jaw clenching and rocking behaviors. Which condition should the nurse anticipate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a client who is diagnosed with Crohn's disease. Which statement made by the client indicates an understanding of the teaching? "I will:

Correct Answer is D

Explanation

Question 92 A client is transferred to the Postanesthesia Care Unit (PACU) after surgery. The priority nursing intervention is:

Correct Answer is C

Explanation

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