Question

A nurse is planning care for a preschooler who has autism spectrum disorder. Which of the following interventions should the nurse include in the plan?

Answer 1

Correct Answers:

Establish a reward system.

Rationale :

🎯Positive reinforcement is a key strategy when working with children who have autism spectrum disorder, as it encourages desired behaviors in a structured and consistent manner.

🧩Children with autism often thrive in environments that are predictable and routine, and reward systems help provide that consistency.

👁️Avoiding excessive eye contact is important, as it may be perceived as threatening or overstimulating to children with autism.

👩‍⚕️Interventions like cooperative play or physical touch (e.g., holding the child) may be inappropriate unless the child demonstrates comfort with such interaction.

📌core message

Use structured reinforcement such as a reward system to support positive behavior in children with autism spectrum disorder.

Answer 2

Correct Answers:

The child swallows frequently

Rationale :

🚨Frequent swallowing following a tonsillectomy may indicate active bleeding, which is a serious and potentially life-threatening complication.

👄Children often do not verbalize bleeding but will swallow blood, especially during sleep or when it pools in the throat.

📈Pain, refusal to drink, or crying are expected postoperative behaviors and are not immediately life-threatening.

👩‍⚕️Prompt recognition of bleeding ensures timely intervention to prevent hemorrhagic shock or airway compromise.

📌core message

Frequent swallowing post-tonsillectomy is a priority sign of hemorrhage and must be addressed immediately.

Answer 3

Correct Answers:

Avoid raw fruits and vegetables in the child's diet.

Rationale :

🛡️Children with neutropenia have a severely compromised immune system and are at high risk for infection.

🥗Raw fruits and vegetables may harbor bacteria or fungi, making them unsafe unless thoroughly cooked or peeled.

📋Vaccines, especially live ones, are generally avoided in neutropenic children due to their weakened immune response.

🚫Rectal temperatures are contraindicated as they may cause mucosal injury and increase the risk of infection.

📌core message

Children with neutropenia should avoid raw produce due to the risk of infection from pathogens.

Answer 4

Correct Answers:

Monitor the newborn's temperature every 2 hr.

Rationale :

🌡️Phototherapy can lead to temperature instability, especially hypothermia or hyperthermia, making regular monitoring essential.

👶Newborns have immature thermoregulation, and changes can occur quickly under phototherapy lights.

👁️Eye checks and skin care are also part of phototherapy, but temperature regulation takes priority in early newborn care.

🚫Applying lotion during phototherapy is contraindicated as it may interfere with light penetration.

📌core message

During phototherapy, regular temperature monitoring helps prevent thermal instability in newborns.

Answer 5

Correct Answers:

FLACC

Rationale :

🧒The FLACC scale is designed for infants and toddlers, especially those who are non-verbal or cognitively impaired.

🔢It assesses pain behaviorally by observing five categories: Face, Legs, Activity, Cry, and Consolability.

👁️Scales like FACES or visual analog require cognitive and communicative ability, which may be impaired in some toddlers.

📈FLACC provides a reliable and objective way to quantify pain in children who cannot self-report.

📌core message

The FLACC scale is ideal for evaluating pain in non-verbal or cognitively impaired toddlers.

Answer 6

Correct Answers:

Administer the next dose as prescribed

Rationale :

💊Vomiting once after digoxin administration is not an automatic indication to hold the next dose unless toxicity is suspected.

👩‍⚕️The nurse should monitor for other signs of digoxin toxicity like bradycardia, nausea, or visual disturbances before altering the dose.

🚫Administering antiemetics or increasing fluids may mask symptoms or worsen fluid overload in heart failure.

📋Documentation and notifying the provider are important, but the default action is to continue therapy unless contraindicated.

📌core message

After a single vomiting episode, the nurse may continue digoxin unless there are signs of toxicity.

Answer 7

Correct Answers:

Keep electrical wires hidden from view.

Rationale :

🔌Electrical cords pose a burn and electrocution risk, especially to curious toddlers who may chew or tug on exposed wires.

💁‍♂️Burn prevention includes controlling access to hazardous materials and appliances in the home.

⚠️Turning pot handles forward or setting water heaters too high are unsafe practices that increase the risk of scalds or contact burns.

☀️Encouraging outdoor activity during peak sun hours can lead to heat injuries, not burn prevention.

📌core message

Prevent burn injuries in toddlers by keeping electrical hazards out of reach.

Answer 8

Correct Answers:

Frequent negative responses

Rationale :

🗣️Toddlers commonly exhibit negativism as they assert independence and test limits with frequent use of the word "no."

📚This is a normal part of toddler development, reflecting their evolving sense of autonomy.

📉They are also emotionally labile, not more emotionally stable, during this period.

👶Increased dependency is not typical; instead, they seek self-control and independence.

📌core message

Toddlers often show negativism as a normal expression of independence during development.

Answer 9

Correct Answers:

Lateral

Rationale :

🛌The lateral position with knees flexed helps widen the vertebral spaces, facilitating safe and accurate lumbar puncture.

👶This position also helps stabilize the child and reduce movement during the procedure.

❌Supine and Semi-Fowler's positions do not provide adequate spinal alignment or access for lumbar puncture.

👩‍⚕️Ensuring proper positioning reduces the risk of complications and failed attempts.

📌core message

The lateral flexed position provides optimal access and safety for a lumbar puncture.

Answer 10

Correct Answers:

Weigh the child once per day

Rationale :

⚖️Daily weights are essential for monitoring fluid retention, which is a hallmark of the acute phase of nephrotic syndrome.

💧Children with nephrotic syndrome are prone to edema and fluid shifts, so accurate tracking is crucial for evaluating treatment response.

🚫Fluid intake is typically restricted, not increased, due to risk of worsening edema or hypertension.

🛌While bed rest may be ordered, positioning is individualized and not the primary concern for monitoring disease status.

📌core message

In nephrotic syndrome, daily weight monitoring helps assess fluid retention and treatment response.

1 :
A nurse is planning care for a preschooler who has autism spectrum disorder. Which of the following interventions should the nurse include in the plan?

📌core message

2 :
A nurse is assessing a preschool-age child who is in the immediate postoperative period following a tonsillectomy. Which of the following assessment findings is the priority?

📌core message

Frequent swallowing post-tonsillectomy is a priority sign of hemorrhage and must be addressed immediately.

3 :
A nurse is planning care for a preschooler who has neutropenia. Which of the following interventions should the nurse include in the plan?

📌core message

4 :
A nurse is caring for a 1 -week-old newborn who has hyperbilirubinemia and is being treated with phototherapy. Which of the following actions should the nurse take?

📌core message

5 :
A nurse is evaluating the pain level of a toddler who is cognitively impaired to a nonpharmacologic intervention. Which of the following pain scales should the nurse use to evaluate the toddler's pain level?

📌core message

6 :
A nurse is caring for an infant who has heart failure and vomited following administration of digoxin. Which of the following actions should the nurse take?

📌core message

7 :
A nurse is reviewing safety measures with a group of parents to prevent burn injuries for toddlers. Which of the following safety measures should the nurse include in the teaching?

📌core message

8 :
A nurse is providing teaching to the guardian of a 2-year-old child about typical toddler behavior. Which of the following behaviors should the nurse include?

📌core message

9 :
A nurse is preparing a child for a lumbar puncture. In which of the following positions should the child be placed for the procedure?

📌core message

10 :
A nurse is planning care for a child who is in the acute stage of nephrotic syndrome. Which of the following interventions should the nurse include in the plan of care?

📌core message

1 : A nurse is planning care for a preschooler who has autism spectrum disorder. Which of the following interventions should the nurse include in the plan?

📌core message

2 : A nurse is assessing a preschool-age child who is in the immediate postoperative period following a tonsillectomy. Which of the following assessment findings is the priority?

📌core message

Frequent swallowing post-tonsillectomy is a priority sign of hemorrhage and must be addressed immediately.

3 : A nurse is planning care for a preschooler who has neutropenia. Which of the following interventions should the nurse include in the plan?

📌core message

4 : A nurse is caring for a 1 -week-old newborn who has hyperbilirubinemia and is being treated with phototherapy. Which of the following actions should the nurse take?

📌core message

5 : A nurse is evaluating the pain level of a toddler who is cognitively impaired to a nonpharmacologic intervention. Which of the following pain scales should the nurse use to evaluate the toddler's pain level?

📌core message

6 : A nurse is caring for an infant who has heart failure and vomited following administration of digoxin. Which of the following actions should the nurse take?

📌core message

7 : A nurse is reviewing safety measures with a group of parents to prevent burn injuries for toddlers. Which of the following safety measures should the nurse include in the teaching?

📌core message

8 : A nurse is providing teaching to the guardian of a 2-year-old child about typical toddler behavior. Which of the following behaviors should the nurse include?

📌core message

9 : A nurse is preparing a child for a lumbar puncture. In which of the following positions should the child be placed for the procedure?

📌core message

10 : A nurse is planning care for a child who is in the acute stage of nephrotic syndrome. Which of the following interventions should the nurse include in the plan of care?

📌core message

1 :
A nurse is planning care for a preschooler who has autism spectrum disorder. Which of the following interventions should the nurse include in the plan?

2 :
A nurse is assessing a preschool-age child who is in the immediate postoperative period following a tonsillectomy. Which of the following assessment findings is the priority?

3 :
A nurse is planning care for a preschooler who has neutropenia. Which of the following interventions should the nurse include in the plan?

4 :
A nurse is caring for a 1 -week-old newborn who has hyperbilirubinemia and is being treated with phototherapy. Which of the following actions should the nurse take?

5 :
A nurse is evaluating the pain level of a toddler who is cognitively impaired to a nonpharmacologic intervention. Which of the following pain scales should the nurse use to evaluate the toddler's pain level?

6 :
A nurse is caring for an infant who has heart failure and vomited following administration of digoxin. Which of the following actions should the nurse take?

7 :
A nurse is reviewing safety measures with a group of parents to prevent burn injuries for toddlers. Which of the following safety measures should the nurse include in the teaching?

8 :
A nurse is providing teaching to the guardian of a 2-year-old child about typical toddler behavior. Which of the following behaviors should the nurse include?

9 :
A nurse is preparing a child for a lumbar puncture. In which of the following positions should the child be placed for the procedure?

10 :
A nurse is planning care for a child who is in the acute stage of nephrotic syndrome. Which of the following interventions should the nurse include in the plan of care?