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A 2-year-old child with a diagnosis of autism spectrum disorder is being discharged. What should the nurse include in the discharge teaching?
- A. Maintain a structured routine
- B. Encourage social interaction
- C. Use positive reinforcement
- D. Use a communication board
Correct Answer: A
Rationale: The correct answer is to maintain a structured routine. Children with autism spectrum disorder benefit greatly from structured routines as they provide a sense of stability and predictability, which can help reduce anxiety and improve behavior. Encouraging social interaction (Choice B) is important but may need to be approached in a structured manner to prevent overwhelming the child. Positive reinforcement (Choice C) is also beneficial for behavior management but may not address the overall need for routine and predictability that is crucial for children with autism. Using a communication board (Choice D) may be helpful for facilitating communication, but establishing and maintaining a structured routine is fundamental for supporting the child's development and well-being in managing their autism spectrum disorder.
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A parent tells the nurse in the emergency department, 'My 3-year-old has had a fever for several days and has been vomiting.' After instituting ordered measures to reduce the fever, what nursing action is most important?
- A. Preventing shivering
- B. Restricting oral fluids
- C. Measuring output hourly
- D. Taking vital signs hourly
Correct Answer: A
Rationale: Preventing shivering is crucial in this scenario as it can increase body temperature and counteract the effects of antipyretic measures aimed at reducing the fever. Shivering generates heat through muscle activity, which can elevate the body temperature. Restricting oral fluids (choice B) is inappropriate as maintaining hydration is vital, especially in cases of fever and vomiting. Measuring output hourly (choice C) and taking vital signs hourly (choice D) are important nursing actions but not the most critical in this case where preventing shivering takes precedence.
What should be included in the preoperative teaching for a 4-year-old child scheduled for a tonsillectomy?
- A. Explaining the procedure in detail
- B. Encouraging deep breathing exercises
- C. Discussing the importance of hydration
- D. Using play therapy to prepare the child
Correct Answer: B
Rationale: Encouraging deep breathing exercises is important preoperative teaching for a child scheduled for a tonsillectomy. Deep breathing exercises can help the child relax and reduce anxiety, which is beneficial before the procedure. Explaining the procedure in detail might be overwhelming for a 4-year-old, whereas encouraging deep breathing exercises can be more beneficial in promoting relaxation and preparing the child. Discussing the importance of hydration is crucial for postoperative care but may not be the priority for preoperative teaching. Using play therapy can help prepare the child, but encouraging deep breathing exercises is more directly related to relaxation and preparation for the procedure.
A child is being assessed for suspected appendicitis. What clinical manifestation is the healthcare professional likely to observe?
- A. Right lower quadrant pain
- B. Left lower quadrant pain
- C. Rebound tenderness
- D. Epigastric pain
Correct Answer: A
Rationale: Right lower quadrant pain is a classic symptom of appendicitis. The appendix is typically located in the right lower quadrant of the abdomen, so pain in this area is commonly associated with appendicitis. Choices B, C, and D are incorrect because left lower quadrant pain, rebound tenderness, and epigastric pain are not typical manifestations of appendicitis. Left lower quadrant pain is not associated with appendicitis since the appendix is situated in the right lower quadrant. Rebound tenderness is more commonly linked with peritonitis rather than appendicitis. Epigastric pain is not a typical presentation of appendicitis as the pain is usually localized to the right lower quadrant.
What intervention best meets a major developmental need of a newborn in the immediate postoperative period?
- A. Giving a pacifier to the newborn
- B. Putting a mobile over the newborn's crib
- C. Providing the newborn with a soft, cuddly toy
- D. Warming the newborn's formula before feeding
Correct Answer: A
Rationale: The correct answer is giving a pacifier to the newborn. Sucking is a natural reflex and a source of comfort for newborns, especially postoperatively. A pacifier can help meet their developmental needs by providing soothing comfort. Choices B, C, and D do not directly address the major developmental need related to the newborn's comfort and reflexes postoperatively. Putting a mobile over the crib, providing a cuddly toy, or warming formula, although potentially beneficial in other contexts, do not specifically target the developmental need of sucking for comfort. Offering a pacifier is a safe and effective way to address this developmental need in newborns.
During a primary survey of a child with partial thickness burns over the upper body areas, what action should the nurse take first?
- A. Inspect the child's skin color.
- B. Assess for a patent airway.
- C. Observe for symmetric breathing.
- D. Palpate the child's pulse.
Correct Answer: B
Rationale: When managing a child with partial thickness burns over the upper body areas, the priority action during the primary survey is to assess for a patent airway. This step is crucial as burns in this region can lead to airway compromise, potentially causing rapid deterioration in the child's condition. Checking for a patent airway ensures that the child can breathe adequately, which is essential for oxygenation and ventilation. Inspecting the child's skin color (Choice A) is an important assessment but should follow ensuring a patent airway. Observing for symmetric breathing (Choice C) is relevant, but the immediate focus should be on securing the airway. Palpating the child's pulse (Choice D) is also a vital assessment, but in this scenario, the priority is to assess and maintain a clear airway to support respiratory function and oxygen delivery.