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The nurse is aware that whenever preparing a school-age child for a procedure, test, or medical treatment, which is the most important information to convey?
- A. When the procedure will take place
- B. Who will perform the procedure
- C. Where the procedure will be performed
- D. What will happen during the procedure
Correct Answer: D
Rationale: Describing what will happen reduces fear of the unknown.
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On the basis of the nurse's knowledge of autistic behavior, which nursing diagnosis is most likely to be a priority in the team conference?
- A. Ineffective health maintenance
- B. Chronic low self-esteem
- C. Risk for activity intolerance
- D. Risk for self-directed violence
Correct Answer: D
Rationale: Self-directed violence is a priority due to potential self-injurious behaviors.
During the nursing assessment, which of the following suggests that the mother may be continuing to abuse heroin?
- A. The mother states, 'I am tired all the time and find myself needing to sleep when the baby sleeps.'
- B. The nurse notes a variety of small ecchymotic areas on the arms and legs of the mother.
- C. The mother appears indifferent to the crying of the newborn.
- D. The mother has a body odor and the newborn appears unkempt.
- E. The mother expresses an inability to afford public transportation to the clinic.
- F. The mother states that the father of the child is no longer associated with the family.
Correct Answer: B,C,D
Rationale: Ecchymotic areas suggest injection sites, indifference may indicate substance use, and poor hygiene is a common sign of ongoing abuse.
When providing care for the 3-year-old autistic child, which behavior is the nurse most likely to note?
- A. Constant use of the words 'I' and 'me'
- B. Insensitivity to pain
- C. Flexibility in normal routine
- D. Increased interest in others' actions
Correct Answer: B
Rationale: Insensitivity to pain is common in autism.
The nurse advises the parents to look for which change as evidence that methylphenidate hydrochloride (Ritalin) is achieving its desired effect?
- A. The child is less easily distracted.
- B. The child does not seem fatigued.
- C. The child's moods are more stable.
- D. None of the above
Correct Answer: A
Rationale: Reduced distractibility indicates improved focus, the primary goal of Ritalin.
When the social worker, who has not had experience with autistic children, asks the nurse to identify signs and symptoms of the disorder, the nurse correctly identifies which finding as most characteristic?
- A. Repetitive body movements
- B. Intense parental attachment
- C. Early sexual development
- D. Profound mental retardation
Correct Answer: A
Rationale: Repetitive movements are a hallmark of autism.