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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Applying warming blankets is important for maintaining the child's body temperature, but it is not the top priority in this situation.
B. Administering an IV bolus may be necessary, but it is not the priority action. The child's airway and breathing take precedence.
C. This is the correct action. In cases of submersion injury, there is a risk of respiratory distress or failure due to aspiration of water. Assisting with intubation helps ensure a patent airway and adequate oxygenation.
D. Obtaining an arterial blood gas (ABG) sample is an important assessment, but it is not the top priority. Ensuring a patent airway and providing adequate oxygenation come first.
Correct Answer is D
Explanation
A. Tremors are not a typical clinical manifestation of heart failure. They may be associated with conditions like hyperthyroidism or certain medications.
B. Bradycardia (slow heart rate) is not a typical finding in heart failure. In fact, tachycardia (fast heart rate) is more commonly associated with this condition.
C. Increased appetite is not a typical clinical manifestation of heart failure. Children with heart failure may actually experience poor appetite due to decreased cardiac output.
D. Correct. Tachypnea (rapid breathing) is a common clinical manifestation of heart
failure. It can occur as the body tries to compensate for the decreased cardiac output by increasing respiratory rate in an effort to maintain oxygenation.
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