Nokea
The nurse is caring for a 3½-year-old child with autism who has been hospitalized. The child rocks continuously without any danger present to the child?s safety. Which intervention by the nurse would be most appropriate?
- A. Continue to monitor the child?s behaviors.
- B. Hold the child until the child stops rocking.
- C. Ignore the child?s rocking behavior.
- D. Place the child in a time out area until the rocking stops.
Correct Answer: C
Rationale: Rocking is a common self-soothing behavior in children with autism and is not harmful in this context. Ignoring the behavior (option C) is most appropriate, as it avoids reinforcing or escalating the behavior while ensuring safety. Option A is passive and less specific. Options B and D could distress the child and are inappropriate for non-harmful behaviors.
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The history of a child newly diagnosed with ADHD reveals that the child is experiencing sleeping difficulties. Which agent would the nurse most likely use?
- A. Methylphenidate
- B. Atomoxetine
- C. Bupropion
- D. Clonidine
Correct Answer: D
Rationale: Clonidine, an alpha-2 agonist, is often used to manage sleep difficulties in children with ADHD, as it has sedative effects. Methylphenidate (option A) and atomoxetine (option B) are stimulants or non-stimulants for ADHD symptoms but may worsen sleep. Bupropion (option C) is an antidepressant and not typically used for ADHD-related sleep issues.
The nurse is counseling a parent whose child has a communication disorder. Which of the following would the nurse emphasize when teaching the parent about this disorder?
- A. Providing the child with nonverbal activities
- B. Initiating conversations with the child frequently
- C. Stopping the child?s conversation if stuttering begins
- D. Asking the physician for medication to improve the child?s speech
Correct Answer: B
Rationale: Initiating frequent conversations encourages communication practice and skill development, which is key for managing communication disorders. Option A may be helpful but is less central than verbal interaction. Option C is counterproductive, as interrupting stuttering can increase anxiety. Option D is inappropriate, as medication is not typically indicated for communication disorders like stuttering.
The mother of a child with Asperger disorder tells the nurse that her child has few playmates. She states, 'He has such poor social skills with other children, and he strongly rejects any change in his routine by throwing a tantrum.' Based on this information, the nurse identifies which nursing diagnosis as the priority?
- A. Self-Care Deficits related to repeated tantrums
- B. Risk for Injury related to Asperger disorder
- C. Ineffective Family Coping related to having a child with Asperger disorder
- D. Risk for Social Isolation related to poor social skills of the child
Correct Answer: D
Rationale: The child?s poor social skills and resulting lack of playmates directly point to the nursing diagnosis of Risk for Social Isolation, as this is a primary concern based on the mother?s statement. Option A is less relevant, as tantrums do not directly relate to self-care deficits. Option B is not supported, as no immediate physical danger is described. Option C may apply but is less specific than social isolation in this context.
The school nurse is caring for a 7-year-old child who has demonstrated a significantly lower-than-average score for mental age on standardized tests in reading. However, the child?s IQ scores were within the average range. The nurse interprets this information as suggesting which of the following?
- A. Communication disorder
- B. Attention deficit hyperactivity disorder
- C. Asperger syndrome
- D. Dyslexia
Correct Answer: D
Rationale: A significantly lower reading score despite an average IQ suggests dyslexia, a learning disorder affecting reading and language processing. Option A is too broad, as communication disorders encompass more than reading issues. Option B (ADHD) typically affects attention, not specifically reading. Option C (Asperger?s) is less likely, as it primarily involves social and behavioral challenges, not reading-specific deficits.
The nurse is giving a presentation comparing and contrasting autism disorder and Asperger syndrome. Which of the following would the nurse include as differentiating Asperger syndrome from autism disorder?
- A. Children typically do not engage in stereotypic behavior.
- B. They display age-appropriate intelligence.
- C. The children often reverse pronouns when speaking.
- D. They appear aloof and indifferent to others.
Correct Answer: B
Rationale: Asperger syndrome is distinguished from autism by the presence of age-appropriate intelligence and language development, though social challenges persist. Option A is incorrect, as stereotypic behaviors may still occur in Asperger?s. Option C is more typical of autism, not Asperger?s. Option D applies to both conditions and does not differentiate them.