Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse at an inpatient facility is planning care for a child who has autism spectrum disorder. Which of the following interventions should the nurse include in the plan of care?
A. Keep staff visits with the child brief.
This is the correct intervention. Children with autism spectrum disorder may have difficulty with social interactions and may become overwhelmed by prolonged or intense interactions. Keeping staff visits brief allows for positive interactions while minimizing potential stress for the child.
B. Vary daily routines when providing care for the child.
Children with autism spectrum disorder often thrive on routines and predictability.Varying daily routines can be distressing and may lead to increased anxiety.
C. Place the child in a semiprivate room.
Placing the child in a semiprivate room may expose them to additional stimuli and potential social interactions, which can be overwhelming for a child with autism spectrum disorder. A private room may provide a quieter and more controlled environment.
D. Keep the television on in the child's room for background noise.
Background noise, such as from a television, can be overstimulating for a child with autism spectrum disorder. It is generally recommended to provide a quiet environment to help the child feel more comfortable and at ease.
This question is an excerpt from Nurse Dive's nursing test bank - RN Nursing Care of Children 2019 with NGN Proctored Exam. Take the full exam now
Full Explanation
A. This is the correct intervention. Children with autism spectrum disorder may have difficulty with social interactions and may become overwhelmed by prolonged or intense interactions. Keeping staff visits brief allows for positive interactions while minimizing potential stress for the child.
B. Children with autism spectrum disorder often thrive on routines and predictability.
Varying daily routines can be distressing and may lead to increased anxiety.
C. Placing the child in a semi-private room may expose them to additional stimuli and potential social interactions, which can be overwhelming for a child with an autism spectrum disorder. A private room may provide a quieter and more controlled environment.
D. Background noise, such as from a television, can be overstimulating for a child with autism spectrum disorder. It is generally recommended to provide a quiet environment to help the child feel more comfortable and at ease.
Similar Questions
A nurse is educating an adolescent following the application of an arm cast. Which of the following statements by the client indicates an understanding of the teaching?
A. "I will elevate my broken arm on pillows at night."
This statement demonstrates understanding. Elevating the broken arm on pillows can help reduce swelling and promote comfort during the night.
B. "I should limit the use of the fingers of my broken arm."
Limiting the use of the fingers of the broken arm is important for proper healing. However, the client should still engage in gentle range-of-motion exercises as instructed by the healthcare provider.
C. "I should expect my fingers to be swollen for several days."
Expecting some degree of swelling in the fingers is normal after the application of a cast. This statement shows understanding.
D. "I will sprinkle baby powder into the cast if my arm itches."
Sprinkling baby powder into the cast if the arm itches is not recommended. It can cause irritation and is not an effective way to address itching under the cast. The client should be instructed not to insert anything into the cast.
Full Explanation
A. This statement demonstrates understanding. Elevating the broken arm on pillows can help reduce swelling and promote comfort during the night.
B. Limiting the use of the fingers of the broken arm is important for proper healing.
However, the client should still engage in gentle range-of-motion exercises as instructed by the healthcare provider.
C. Expecting some degree of swelling in the fingers is normal after the application of a cast. This statement shows understanding.
D. Sprinkling baby powder into the cast if the arm itches is not recommended. It can cause irritation and is not an effective way to address itching under the cast. The client should be instructed not to insert anything into the cast.
A nurse is planning to perform tracheostomy care for a toddler. Which of the following is an appropriate action for the nurse to take?
A. Place the child in Trendelenburg position when performing care.
Placing the child in Trendelenburg position is not necessary for tracheostomy care. In fact, this position is generally not recommended for routine tracheostomy care.
B. Use clean technique to change the tracheostomy tube.
Sterile technique, not clean technique, should be used when changing the tracheostomy tube to reduce the risk of infection.
C. Have the child flex his head when securing the ties.
This is the correct action. Having the child flex his head can help prevent tension on the tracheostomy ties and ensure a secure and comfortable fit.
D. Clean around the stoma with full-strength hydrogen peroxide.
Full-strength hydrogen peroxide is too harsh and can cause irritation to the skin around the stoma. It is recommended to use normal saline or a mild soap and water solution for cleaning.
Full Explanation
A. Placing the child in the Trendelenburg position is not necessary for tracheostomy care. In fact, this position is generally not recommended for routine tracheostomy care.
B. Sterile technique, not clean technique, should be used when changing the tracheostomy tube to reduce the risk of infection.
C. This is the correct action. Having the child flex his head can help prevent tension on the tracheostomy ties and ensure a secure and comfortable fit.
D. Full-strength hydrogen peroxide is too harsh and can cause irritation to the skin around the stoma. It is recommended to use normal saline or a mild soap and water solution for cleaning.
A nurse is assessing a 24-month-old toddler. Which of the following findings should the nurse report to the provider?
A. Eats a large amount of food one day then very little the next
Eating a large amount of food one day and very little the next is a normal eating pattern for toddlers. They may have days when they eat more and days when they eat less.
B. Holds his breath when having a temper tantrum
This finding should be reported to the provider. Breath-holding spells during temper tantrums can be concerning and may require further evaluation.
C. Sleeps 11 to 12 hr per day
Toddlers typically need about 11-14 hours of sleep per day, so sleeping 11 to 12 hours is within the normal range.
D. Has a vocabulary of 30 words
A vocabulary of 30 words is considered normal for a 24-month-old toddler.
Full Explanation
A. Eating a large amount of food one day and very little the next is a normal eating pattern for toddlers. They may have days when they eat more and days when they eat less.
B. This finding should be reported to the provider. Breath-holding spells during temper tantrums can be concerning and may require further evaluation.
C. Toddlers typically need about 11-14 hours of sleep per day, so sleeping 11 to 12 hours is within the normal range.
D. A vocabulary of 30 words is considered normal for a 24-month-old toddler.