A school-age client diagnosed with autism is admitted to the hospital because of recent vomiting and diarrhea. Which intervention by the nurse is most appropriate upon admission?
Take the child on a tour of the whole unit to familiarize with the surroundings.
Admit the child to a four-bed room to allow interaction with peers.
Orient the child to the hospital room.
Take the child to the playroom immediately to participate in the arts and crafts activity.
The Correct Answer is C
Choice A reason: Taking the child on a tour might be overwhelming and increase anxiety due to the new environment and sensory overload.
Choice B reason: Placing the child in a four-bed room could lead to overstimulation and discomfort due to the presence of multiple unfamiliar people.
Choice C reason: Orienting the child to the hospital room provides a safe and controlled environment, allowing for gradual adjustment to the new setting.
Choice D reason: Immediately taking the child to the playroom for arts and crafts might be too stimulating and could exacerbate stress rather than ease the transition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: While monitoring blood pressure and symptoms is important, it is not a self-management outcome.
Choice B reason: Taking up to 4 nitroglycerine tablets may be part of the treatment plan, but it is not an outcome.
Choice C reason: Encouraging daily exercise is good, but it does not address the management of chest pain on exertion.
Choice D reason: This is the correct choice. Recording episodes of angina and self-management strategies provides valuable information for adjusting treatment and empowering the patient.
Correct Answer is D
Explanation
Choice A reason: Movement of all extremities is expected and does not indicate a shunt malfunction.
Choice B reason: A negative Brudzinski sign is a normal finding and does not suggest a shunt malfunction.
Choice C reason: While incisional pain is common after surgery, it is not a specific indicator of shunt malfunction.
Choice D reason: This is the correct choice. A bulging fontanel can indicate increased intracranial pressure, which may suggest a shunt malfunction.
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