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

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.

A. Oliguria (decreased urine output) is not typically associated with hypokalemia. It can be a symptom of other electrolyte imbalances or kidney dysfunction.

B. Hypertension (high blood pressure) is not a typical finding in a child with hypokalemia. Low potassium levels are more likely to be associated with cardiac dysrhythmias and hypotension.

C. Hyperactive bowel sounds are not directly related to hypokalemia. They can occur in various gastrointestinal conditions, but they are not a specific indicator of potassium
levels.

D. This is the correct answer. Hypokalemia (low potassium levels) can lead to decreased neuromuscular excitability, which can result in hyporeflexia (reduced reflexes). This is an important neurological sign associated with low potassium levels.