The nurse is observing a group of 2- and 3-year-olds in a playgroup.
Which behavior noted in one of the children indicates to the nurse that the child may have autism spectrum disorder (ASD)?
After another child takes a toy, the child cries and stomps his feet.
A child playing in the kitchen area pretends to pour a glass of milk and repeats this over and over.
While the other children are eating a snack, the child walks around the room feeling the walls and ignores the caregiver who offers him a snack.
A child flips the light switch off and on until the caregiver asks her to stop and join the other children in play.
The Correct Answer is C
A child with autism spectrum disorder may have problems with social communication and interaction, including ignoring a caregiver who offers them a snack.
Choice A is incorrect because crying and stomping feet after another child takes a toy is normal behavior for a 2- or 3-year-old child.
Choice B is incorrect because repeating an action over and over is not necessarily indicative of autism spectrum disorder.
Choice D is incorrect because flipping a light switch off and on until asked to stop and join other children in playing is not necessarily indicative of autism spectrum disorder.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The proof of pregnancy is in the pregnancy test.
A positive office pregnancy test would confirm the pregnancy.
Choice A, Chadwick’s sign, is not correct because it is not a definitive sign of pregnancy.
Choice B, Hegar’s sign, is also not correct because it is not a definitive sign of pregnancy.
Choice D, Fetal movement felt by the examiner, is not correct because it is not a definitive sign of pregnancy.
Correct Answer is C
Explanation
Choice A reason:
Placing traction weights so they touch the head of the bed disrupts the effectiveness of the traction system. Skeletal traction relies on a continuous pulling force to maintain proper alignment of the fractured femur. If the weights are resting on any surface, the force is interrupted, which can lead to complications such as malunion or delayed healing. The weights must hang freely at all times to ensure therapeutic benefit.
Choice B reason:
Isometric exercises are beneficial for maintaining muscle tone and promoting circulation during immobilization. However, while this is a supportive intervention, it is not the most critical or immediate nursing action in the context of skeletal traction. Encouraging exercises every 8 hours is appropriate, but it does not directly address the most urgent or discomfort-related aspect of care.
Choice C reason:
Pin care is a routine but potentially painful procedure associated with skeletal traction. Administering pain medication beforehand is a priority nursing action because it ensures client comfort, reduces anxiety, and promotes cooperation during the procedure. This intervention reflects both compassionate care and adherence to best practices in pain management and infection prevention.
Choice D reason:
Repositioning a client in skeletal traction must be done with extreme caution to avoid disrupting the traction setup. Assisting the client to shift position every 4 hours may inadvertently alter the alignment or tension of the traction apparatus. While pressure injury prevention is important, repositioning must be coordinated carefully and is not the most appropriate standalone action in this context.
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