A nurse is caring for a client who has autism spectrum disorder. Which of the following findings should the nurse expect?

Expressive affect

Ambivalence

Echolalia

Associative looseness

Answer and Explanation

The Correct Answer is C

A. Expressive affect: Individuals with autism spectrum disorder (ASD) often have difficulty expressing their emotions in a typical manner. They may display a restricted range of facial expressions or have difficulty conveying emotions through facial expressions and gestures. However, "expressive affect" typically refers to the appropriate display of emotions, which may not be characteristic of ASD.

B. Ambivalence: Ambivalence refers to conflicting feelings or attitudes about a situation or person. While individuals with ASD may experience a range of emotions, including ambivalence, it is not a specific characteristic associated with the disorder. Ambivalence is a common human experience and may occur in individuals with or without ASD.

C. Echolalia: Echolalia is a common communication characteristic observed in individuals with ASD. It involves the repetition or echoing of words or phrases spoken by others. This behavior may occur immediately after hearing the words or phrases (immediate echolalia) or may be delayed. Echolalia can serve various functions, including communication, self-regulation, or expression of anxiety.

D. Associative looseness: Associative looseness is a thought disorder characterized by a lack of logical connection between thoughts and ideas. It is typically associated with conditions such as schizophrenia rather than ASD. Individuals with ASD may exhibit difficulties with social communication, including challenges in maintaining conversations or understanding social cues, but this is different from the disorganized thinking observed in associative looseness.

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Correct Answer is D

Explanation

A. Use a 1.8 mm (0.5 in) needle:

Rationale: Needle length is typically not measured in millimeters for intramuscular injections. The length of the needle for intramuscular injections in preschoolers is usually longer, ranging from 16 to 25 mm (5/8 to 1 inch), depending on factors such as the child's size and the thickness of adipose tissue at the injection site.

B. Use a 20-gauge needle:

Rationale: While the gauge of the needle is important for controlling the flow rate of the medication, the size of the gauge alone does not determine the appropriateness of the needle for administering a vaccine into the deltoid muscle of a preschooler. The gauge of the needle commonly used for intramuscular injections in children is typically between 22 and 25 gauge.

C. Insert the needle at a 15-degree angle:

Rationale: When administering an intramuscular injection into the deltoid muscle, the needle should be inserted at a 90-degree angle (perpendicular to the skin) for children and adults. Using a 15-degree angle would result in a subcutaneous injection rather than reaching the muscle tissue.

D. Insert the needle just below the acromion process:

This is the correct action. When administering a vaccine into the deltoid muscle of a preschooler, the nurse should insert the needle just below the acromion process. This landmark helps ensure accurate placement of the needle into the deltoid muscle, which is the recommended site for intramuscular injections in preschool-age children.

A. Before auscultating the chest and abdomen B. Before examining the head and neck C. At the end D. At the beginning

Correct Answer is C

Explanation

A. Before auscultating the chest and abdomen: Examining the tympanic membrane before auscultating the chest and abdomen is not ideal. It's important to follow a systematic approach in physical examination, typically starting with less invasive assessments before progressing to more invasive or uncomfortable ones. Therefore, examining the tympanic membrane before auscultating the chest and abdomen may disrupt this systematic approach.

B. Before examining the head and neck: Similarly, examining the tympanic membrane before examining the head and neck is not appropriate. The head and neck examination typically includes less invasive assessments such as observing the child's appearance, palpating the fontanelles, and inspecting the scalp, face, and neck. The tympanic membrane examination, which involves using an otoscope, is more invasive and should be performed later in the examination.

C. At the end: This is the correct choice. Examining the tympanic membrane at the end of the physical examination allows the nurse to establish rapport with the child and gain their cooperation before performing a potentially uncomfortable or intrusive examination of the ears. Starting with less invasive and more familiar assessments, such as observing the child's general appearance and behavior, auscultating the chest and abdomen, and examining the head and neck, can help build trust and reduce anxiety before proceeding to more specific assessments, such as otoscopy.

D. At the beginning: Examining the tympanic membrane at the beginning of the physical examination may cause the child distress and anxiety, potentially making the rest of the examination more challenging. It's preferable to perform less invasive assessments first to help the child become more comfortable and cooperative before proceeding to more invasive examinations like otoscopy. Therefore, examining the tympanic membrane at the beginning is not recommended.

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A nurse is caring for a client who has autism spectrum disorder. Which of the following findings should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer a vaccine into the deltoid muscle of a preschooler. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is assessing a toddler at a well-child visit. At what point in the physical examination should the nurse examine the child's tympanic membrane??

Correct Answer is C

Explanation

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