Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
The nurse is collecting data on an 18-month-old child with a diagnosis of autism spectrum disorder (ASD).
What clinical manifestation would likely have been noted in the child with this diagnosis?
A. The child does not make eye contact.
One of the common symptoms of autism spectrum disorder (ASD) is difficulty with social communication and interaction, which can include avoiding or not keeping eye contact.
B. The child sits quietly in the caregiver's lap during the interview.
Choice B is not an answer because sitting quietly in the caregiver’s lap during the interview is not a typical symptom of ASD.
C. The child smiles when the caregiver shows her a stuffed animal.
Choice C is not an answer because smiling when shown a stuffed animal is not a typical symptom of ASD.
D. The child cries and runs to the door when the caregiver leaves the room.
Choice D is not an answer because crying and running to the door when the caregiver leaves the room is not typical symptom of ASD.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Custom- Wn23 NS122 Proctored Exam. Take the full exam now
Full Explanation
One of the common symptoms of autism spectrum disorder (ASD) is difficulty with social communication and interaction, which can include avoiding or not keeping eye contact.
Choice B is not an answer because sitting quietly in the caregiver’s lap during the interview is not a typical symptom of ASD.
Choice C is not an answer because smiling when shown a stuffed animal is not a typical symptom of ASD.
Choice D is not an answer because crying and running to the door when the caregiver leaves the room is not typical symptom of ASD.
Similar Questions
The nurse discovers a new prescription for RhoGAM for a client who is about to undergo a diagnostic procedure.
The nurse will administer the RhoGAM after which procedure?
A. Amniocentesis.
This is a diagnostic procedure that involves inserting a needle into the uterus to obtain a sample of amniotic fluid for testing. This procedure can cause a small amount of fetal blood to enter the maternal circulation, which can trigger an immune response in Rh-negative women carrying Rh-positive fetuses. RhoGAM is a medication that contains antibodies against the Rh factor and prevents the mother from developing her own antibodies that could harm the fetus or future pregnancies. RhoGAM should be given within 72 hours after amniocentesis to Rh-negative women who are not already sensitized2.
B. Biophysical Profile.
Biophysical Profile is incorrect, as this is a noninvasive diagnostic procedure that involves ultrasound and fetal heart rate monitoring to assess fetal well-being. This procedure does not cause fetomaternal hemorrhage and does not require RhoGAM administration.
C. Contraction stress test.
The contraction stress test is incorrect, as this is a noninvasive diagnostic procedure that involves inducing uterine contractions and monitoring fetal heart rate response to assess fetal oxygenation. This procedure does not cause fetomaternal hemorrhage and does not require RhoGAM administration.
D. Nonstress test.
A nonstress test is incorrect, as this is a noninvasive diagnostic procedure that involves monitoring fetal heart rate and movement to assess fetal well-being. This procedure does not cause fetomaternal hemorrhage and does not require RhoGAM administration.
Full Explanation
This is a diagnostic procedure that involves inserting a needle into the uterus to obtain a sample of amniotic fluid for testing.
This procedure can cause a small amount of fetal blood to enter the maternal circulation, which can trigger an immune response in Rh-negative women carrying Rh-positive fetuses.
RhoGAM is a medication that contains antibodies against the Rh factor and prevents the mother from developing her own antibodies that could harm the fetus or future pregnancies.
RhoGAM should be given within 72 hours after amniocentesis to Rh-negative women who are not already sensitized2.
Choice B.
Biophysical Profile is incorrect, as this is a noninvasive diagnostic procedure that involves ultrasound and fetal heart rate monitoring to assess fetal well-being.
This procedure does not cause fetomaternal hemorrhage and does not require RhoGAM administration.
Choice C.
The contraction stress test is incorrect, as this is a noninvasive diagnostic procedure that involves inducing uterine contractions and monitoring fetal heart rate response to assess fetal oxygenation.
This procedure does not cause fetomaternal hemorrhage and does not require RhoGAM administration.
Choice D.
A nonstress test is incorrect, as this is a noninvasive diagnostic procedure that involves monitoring fetal heart rate and movement to assess fetal well-being.
This procedure does not cause fetomaternal hemorrhage and does not require RhoGAM administration.
Therefore, choice A is the best answer to this question.
A nurse is preparing to administer prophylactic eye ointment to a newborn to prevent ophthalmia neonatorum.
Which of the following medications should the nurse anticipate administering?
A. Nystatin.
Nystatin is incorrect, as this is an antifungal medication that is used to treat oral thrush or diaper rash in newborns, not eye infections.
B. Ceftriaxone.
Ceftriaxone is incorrect, as this is an antibiotic injection that is used to treat systemic gonorrhea infections in adults or newborns, not eye infections.
C. Erythromycin.
This is an antibiotic ointment that is applied to the eyes of newborns to prevent ophthalmia neonatorum, a serious eye infection caused by gonorrhea. Ophthalmia neonatorum can cause blindness if left untreated and can occur even if the mother does not have symptoms of gonorrhea. Erythromycin is the only drug approved by the FDA for this purpose and is mandated in most states.
D. Ofloxacin.
Ofloxacin is incorrect, as this is an antibiotic eye drop that is used to treat bacterial conjunctivitis in older children and adults, not ophthalmia neonatorum in newborns. Therefore, choice C is the best answer to this question.
Full Explanation
This is an antibiotic ointment that is applied to the eyes of newborns to prevent ophthalmia neonatorum, a serious eye infection caused by gonorrhea.
Ophthalmia neonatorum can cause blindness if left untreated and can occur even if the mother does not have symptoms of gonorrhea.
Erythromycin is the only drug approved by the FDA for this purpose and is mandated in most states.
Choice A.
Nystatin is incorrect, as this is an antifungal medication that is used to treat oral thrush or diaper rash in newborns, not eye infections.
Choice B.
Ceftriaxone is incorrect, as this is an antibiotic injection that is used to treat systemic gonorrhea infections in adults or newborns, not eye infections.
Choice D.
Ofloxacin is incorrect, as this is an antibiotic eye drop that is used to treat bacterial conjunctivitis in older children and adults, not ophthalmia neonatorum in newborns.
Therefore, choice C is the best answer to this question.
The parents of a preschooler diagnosed with muscular dystrophy are asking questions about the course of their child's disease.
The nurse should tell them which of the following?
A. Muscular dystrophies are disorders associated with progressive degeneration of muscles, resulting in relentless and increasing weakness.
Muscular dystrophies are disorders associated with progressive degeneration of muscles, resulting in relentless and increasing weakness. This is a general description of muscular dystrophy, a group of genetic diseases that affect different types of muscles and cause various degrees of disability. Children with muscular dystrophy may experience frequent falls, difficulty walking or running, muscle pain, learning difficulties, and breathing problems. There is no cure for muscular dystrophy, but treatments can help manage symptoms and slow down the progression of the disease.
B. The extent of degeneration depends on performing daily physical therapy.
The extent of degeneration depends on performing daily physical therapy is incorrect, as physical therapy cannot prevent or reverse the degeneration of muscles caused by muscular dystrophy. Physical therapy can help maintain muscle strength and flexibility, prevent contractures and deformities, and improve mobility and function.
C. The child will be able to function normally and require no special accommodations.
The child will be able to function normally and require no special accommodations is incorrect, as muscular dystrophy affects the child’s ability to perform daily activities and may require assistive devices, such as braces, wheelchairs, or ventilators. The child may also need special education services, occupational therapy, speech therapy, or psychological counseling to cope with the disease.
D. The weakness that the child is currently experiencing will probably not increase.
The weakness that the child is currently experiencing will probably not increase incorrectly, as muscular dystrophy is a progressive disease that causes muscle weakness to worsen over time. The rate and severity of progression may vary depending on the type and subtype of muscular dystrophy.
Full Explanation
Muscular dystrophies are disorders associated with progressive degeneration of muscles, resulting in relentless and increasing weakness.
This is a general description of muscular dystrophy, a group of genetic diseases that affect different types of muscles and cause various degrees of disability.
Children with muscular dystrophy may experience frequent falls, difficulty walking or running, muscle pain, learning difficulties, and breathing problems.
There is no cure for muscular dystrophy, but treatments can help manage symptoms and slow down the progression of the disease.
Choice B.
The extent of degeneration depends on performing daily physical therapy is incorrect, as physical therapy cannot prevent or reverse the degeneration of muscles caused by muscular dystrophy.
Physical therapy can help maintain muscle strength and flexibility, prevent contractures and deformities, and improve mobility and function.
Choice C.
The child will be able to function normally and require no special accommodations is incorrect, as muscular dystrophy affects the child’s ability to perform daily activities and may require assistive devices, such as braces, wheelchairs, or ventilators.
The child may also need special education services, occupational therapy, speech therapy, or psychological counseling to cope with the disease.
Choice D.
The weakness that the child is currently experiencing will probably not increase incorrectly, as muscular dystrophy is a progressive disease that causes muscle weakness to worsen over time.
The rate and severity of progression may vary depending on the type and subtype of muscular dystrophy.
Therefore, choice A is the best answer to this question.