A nurse is planning care for a newly admitted child who has autism spectrum disorder. Which of the following interventions should the nurse include in the plan?
Establish a reward system for the child.
Limit parent visits with the child.
Keep the door to the child's room open.
Leave a television on during the night.
The Correct Answer is A
A. Establish a reward system for the child. Positive reinforcement encourages desired behaviors and helps manage challenging behaviors.
B. Limit parent visits with the child. Parental presence is comforting for children with autism and helps maintain their routine.
C. Keep the door to the child's room open. A calm and controlled environment is essential; an open door can increase stimuli.
D. Leave a television on during the night. Excess noise or stimuli, especially during rest periods, can increase anxiety in children with autism.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "Chill the medication prior to administration." The medication should be warmed to room temperature to prevent discomfort or dizziness during administration.
B. "Pull the pinna up and back during medication administration." For infants, the pinna should be pulled down and back to straighten the ear canal.
C. "Hyperextend the infant's neck during medication administration." Hyperextending the neck is unnecessary and may cause discomfort; a neutral position is sufficient.
D. "Massage the anterior area of the ear following administration." Massaging the tragus helps ensure the medication is evenly distributed into the ear canal.
Correct Answer is ["B","E"]
Explanation
A. "Bounding peripheral pulses." Bounding pulses are not characteristic of Tetralogy of Fallot. Instead, pulses may be normal or diminished, depending on the severity of the defect.
B. "Cyanotic spells." Tetralogy of Fallot causes decreased oxygenation, leading to periodic cyanotic episodes, particularly during crying or feeding ("tet spells").
C. "Stridor." Stridor is associated with upper airway obstructions, not cardiac defects like Tetralogy of Fallot.
D. "Anemia." Anemia is not a primary finding in Tetralogy of Fallot. Polycythemia (increased red blood cells) is more common due to chronic hypoxia.
E. "Heart murmur." A systolic murmur is common due to the pulmonary stenosis and ventricular septal defect associated with Tetralogy of Fallot.
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