A nurse at an inpatient facility is planning care for a child who has autism spectrum disorder. Which of the following interventions should the nurse include in the plan of care?

Keep staff visits with the child brief.

Vary daily routines when providing care for the child.

Place the child in a semiprivate room.

Keep the television on in the child's room for background noise.

Answer and Explanation

The Correct Answer is A

A. This is the correct intervention. Children with autism spectrum disorder may have difficulty with social interactions and may become overwhelmed by prolonged or intense interactions. Keeping staff visits brief allows for positive interactions while minimizing potential stress for the child.

B. Children with autism spectrum disorder often thrive on routines and predictability.
Varying daily routines can be distressing and may lead to increased anxiety.

C. Placing the child in a semi-private room may expose them to additional stimuli and potential social interactions, which can be overwhelming for a child with an autism spectrum disorder. A private room may provide a quieter and more controlled environment.

D. Background noise, such as from a television, can be overstimulating for a child with autism spectrum disorder. It is generally recommended to provide a quiet environment to help the child feel more comfortable and at ease.

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Correct Answer is D

Explanation

A. Dark brown blood in emesis is expected postoperatively due to swallowed blood and does not require immediate intervention.
B. A mild fever (38°C or 100°F) can occur postoperatively and is not an emergency.
C. Pain is expected after a tonsillectomy and should be managed but does not require immediate intervention.
D. Frequent swallowing may indicate active bleeding from the surgical site, which requires immediate assessment and intervention.

A. Provide a pacifier coated with an oral sucrose solution prior to the injections. B. Inject the immunizations into the deltoid muscle. C. Use a 20-gauge needle for the injections. D. Apply eutectic mixture of local anesthetics (EMLA) cream immediately before the injections.

Correct Answer is A

Explanation

A. This is the correct action. Offering a pacifier coated with an oral sucrose solution before the injections can provide comfort and help alleviate pain associated with the immunizations.

B. Administering immunizations into the deltoid muscle is not recommended for infants.
For young infants, immunizations are typically given in the anterolateral thigh muscle.

C. Using a 20-gauge needle is not recommended for infants, as it is a larger gauge and may cause more discomfort. A smaller gauge needle is typically used for infant
immunizations.

D. Applying an eutectic mixture of local anesthetics (EMLA) cream immediately before the injections is not a standard practice for routine infant immunizations. It may not be necessary for most infants and could increase the overall time and complexity of the procedure.

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A nurse at an inpatient facility is planning care for a child who has autism spectrum disorder. Which of the following interventions should the nurse include in the plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a child in the PACU following a tonsillectomy. Which of the following findings requires immediate intervention by the nurse?

Correct Answer is D

Explanation

A nurse is preparing to administer immunizations to a 3-month-old infant. Which of the following is an appropriate action for the nurse to take to deliver atraumatic care?

Correct Answer is A

Explanation

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