Semester 3 Unit 5
Which question would the nurse ask while assessing a Hispanic woman with depression for the risk of self-harm? "When did you last spend time with friends?" "How do you express yourself when you're angry?" "When did you first notice that you were depressed?" "Do you have interests outside your work and home?"
"How do you express yourself when you're angry?" The nurse would ask, "How do you express yourself when you're angry?" The Hispanic culture tends to limit the ways in which a woman can acceptably express anger and frustration, and this results in a higher risk for suicidal behavior. Asking when the client last spent time with friends, when she noticed that she was depressed, or whether she has interests outside her home and work, although appropriate, are not culturally focused.
The nurse is caring for a client taking a selective serotonin reuptake inhibitor (SSRI) for depression. Which statement by the client requires additional teaching? "I should take the medication at the same time daily." "I can stop taking this medication when I feel better." "I will exercise to control any weight gain the medication may cause." "I need to report any agitation I experience to the health care provider."
"I can stop taking this medication when I feel better." Clients should never abruptly discontinue an SSRI, because this can cause withdrawal syndrome. The symptoms of withdrawal include dizziness, nausea, sensory disturbances, and dysphoria. Clients will be instructed to take the medication at the same time every day, to increase exercise if the medication contributes to weight gain, and to report any increase in anxiety or agitation to the health care provider.
While assessing a newborn suspected of having Down syndrome, which would the nurse expect to note as part of the findings? Long, thin fingers Large, protruding ears Hypertonic neck muscles A single crease across each palm
A single crease across each palm A single crease across the palm of each hand, a characteristic finding in newborns with Down syndrome, is known as a simian crease. Stubby fingers, not long, slim fingers, are commonly found in newborns with Down syndrome. Small ears, not large, protruding ears, are commonly found in newborns with Down syndrome. Newborns with Down syndrome have hypotonic, not hypertonic, muscles.
A client reports to the nurse becoming panicked and having an irrational fear of talking in public. Which medication would the nurse anticipate developing a teaching plan for? Buspirone Alprazolam Diazepam Lorazepam
Alprazolam Alprazolam (a benzodiazepine) is a short-acting anxiolytic medication used to treat those clients with panic disorders and the irrational fear of talking openly in public (agoraphobia). Buspirone, an anxiolytic medication that is different both chemically and pharmacologically from the benzodiazepines, is always administered on a scheduled basis (not on an as-needed basis) for the treatment of anxiety. Diazepam is an anxiolytic medication commonly prescribed for the treatment of anxiety but has generally been replaced by short-acting benzodiazepines. Lorazepam is an intermediate-acting anxiolytic medication used in the treatment of acutely agitated clients. View Topics
A client with the diagnosis of panic disorder refuses to take the prescribed alprazolam because of fears of addiction. Which action would the nurse perform first? Give verbal and written information about alprazolam. Assess the client's beliefs and knowledge of alprazolam. Ask the health care provider to change the medication. Ask the health care provider to explain addiction risks.
Assess the client's beliefs and knowledge of alprazolam. Before deciding how to ease the client's fears of addiction, the nurse must explore the full extent of the client's knowledge and beliefs about taking this medication. Information may or may not be helpful; the client's beliefs must be addressed. The nurse may eventually ask the health care provider to consider changing the medication or to speak with the client about safety and risk.
Which behavior is characteristic of panic during a crisis? Being physically immobile Sobbing for no apparent reason Difficulties with falling asleep Startling to loud noises and touch
Being physically immobile Being unable to physically move is a psychomotor characteristic of extreme panic during a crisis. Sobbing, difficulties with sleep, and startling are associated with lower levels of anxiety.
Which statements would the nurse report to the health care provider as possible signs and symptoms of depression for a school-aged child? Select all that apply. One, some, or all responses may be correct. Child tells the nurse, "My parents are getting a divorce, because I was bad." Mom says, "He spends a lot of time by himself moping or watching television." Teacher indicates, "His grades, performance, and general interest have declined." Dad reports, "He is very focused on a craft project and frequently shows me his work." Sister says, "He bothers me all of the time and then he hits me if I don't pay attention."
Child tells the nurse, "My parents are getting a divorce, because I was bad." Mom says, "He spends a lot of time by himself moping or watching television." Teacher indicates, "His grades, performance, and general interest have declined." Sister says, "He bothers me all of the time and then he hits me if I don't pay attention." Children are less able to directly verbalize their feelings, so health care staff, parents, and educators should be vigilant for behavior changes or verbalization that would include assuming responsibility for a negative event, such as divorce. Solitary behavior, decreased motor activity, changes in school performance, and increased attention-seeking behavior or aggressiveness can signal depression. Interest in a project and desire to share successes and obtain feedback from a parent is an expected healthy behavior for a school-aged child.
Which clinical finding would prompt the nurse to perform further assessment of an infant with Down syndrome? Flat occiput Small, low-set ears Circumoral cyanosis Protruding furrowed tongue
Circumoral cyanosis Circumoral cyanosis is not a specific characteristic of Down syndrome. It is a clinical finding associated with congenital heart disease, which may co-occur in a child with Down syndrome. A flat occiput and a broad nose with a depressed bridge (saddle nose) are features of children with Down syndrome. Small, misshapen, low-set ears are also a clinical manifestation of Down syndrome. Children with Down syndrome often keep their mouths open, with their tongues protruding; the surface of the tongue is often wrinkled.
Which comorbidity is associated Down syndrome? Renal disease Hepatic defects Congenital heart disease Endocrine gland malfunction
Congenital heart disease Many children with Down syndrome have cardiac anomalies, most often ventricular septal defects, which can be life threatening. Renal disease, hepatic defects, and endocrine gland malfunction are not characteristic findings in children with Down syndrome.
Which goal would cognitive therapy accomplish for a client who experiences panic attacks? Prevent future panic attacks. Help the client hide the panic attacks. Stop the panic attacks once they begin. Decrease the fear of having panic attacks.
Decrease the fear of having panic attacks. The goal of cognitive therapy for panic attacks is to decrease the fear of having panic attacks. It is the fear of having an attack as much as the panic attack itself that is debilitating. Once the client's fear of future attacks is diminished, the number of attacks usually decreases as well. Prevention of future attacks is desirable but not always possible with cognitive therapy. Hiding the attacks is not a goal of cognitive therapy. Assisting the client to cope would be more helpful. It usually is impossible to stop a panic attack once it starts.
The parent of an infant with Down syndrome asks the cause. Before responding, the nurse recalls that the genetic factor of Down syndrome results from which? An intrauterine infection An X-linked genetic disorder Extra chromosomal material An autosomal recessive gene
Extra chromosomal material Down syndrome (trisomy 21) results from extra chromosomal material on chromosome 21. Down syndrome does not result from a maternal infection. Down syndrome is not related to an X-linked or Y-linked gene. An autosomal recessive gene is not the cause of Down syndrome, although translocation of chromosomes 15 and 21 or 22 is a genetic aberration found in some children with Down syndrome.
For a child with attention-deficit/hyperactivity disorder (ADHD), which behaviors are expected? Select all that apply. One, some, or all responses may be correct. Impulsiveness Excessive talking Spitefulness and vindictiveness Deliberate annoyance of others Playing video games for hours on end Failure to follow through or finish tasks
Impulsiveness Excessive talking Playing video games for hours on end Failure to follow through or finish tasks Impulsivity, the inability to limit or control words or actions, results in spontaneous, irresponsible verbalizations or behaviors. Hyperactivity occurs with both words and actions. Games that are fun, engaging, and interactive often maintain the focus of a child with ADHD. Inattention and distractibility result in inability to focus long enough to complete tasks. Being spiteful and vindictive toward others is characteristic of oppositional defiant disorder. Deliberately annoying others is associated with oppositional defiant disorder; children with ADHD may be annoying, but their behavior is not deliberate.
Which nursing objective would the nurse add to the plan of care for a child with attention-deficit/hyperactivity disorder (ADHD) who engages in self-destructive behavior? Keeping the child from inflicting any self-injury Assisting the child to improve communication skills Helping the child formulate realistic ego boundaries Providing the child with opportunities to discharge energy
Keeping the child from inflicting any self-injury The nursing objective is to keep the child from inflicting any self-injury. All nursing care would be directed toward preventing injury, particularly with a self-destructive child. Although improved communication skills are important, this is usually not an issue with ADHD. Although formulation of realistic ego boundaries is important, it is not the priority. Opportunities to discharge energy are important, but prevention of injury is the priority.
A client diagnosed with depression is prescribed phenelzine. The nurse understands that which foods, if consumed along with this medication, may cause a hypertensive crisis? Select all that apply. One, some, or all responses may be correct. Yogurt Red wine Cream cheese Aged meat Aged cheese
Red wine Aged meat Aged cheese Monoamine oxidase inhibitors (MAOIs) including phenelzine may cause hypertensive crisis if the client concurrently consumes foods rich in tyramine. Red wine, aged meat, and aged cheese contain high amounts of tyramine. Yogurt and cream cheese have low tyramine content and are considered permissible.
Which play activity is the best choice to suggest to the parents of a school-aged child with autism? Holding a cuddly toy Climbing a jungle gym Building with small blocks Riding on a playground merry-go-round
Riding on a playground merry-go-round The rhythmic movement of the merry-go-round provides an opportunity for the child to practice spatial and sensory orientation. This is important in helping the child increase interaction with the environment. The autistic child rejects cuddling and anything that feels cuddly. Jungle gyms and blocks do not provide rhythmic movements that will engage the child.
Which descriptions would the nurse expect to hear from a client describing experiences of panic? Select all that apply. One, some, or all responses may be correct. Severe withdrawal Hallucinations or delusions A decreased need for sleep Being more talkative than usual or feeling pressure to keep talking Flight of ideas or the subjective experience that thoughts are racing Feeling unreal (depersonalization) or that the world is unreal (derealization)
Severe withdrawal Hallucinations or delusions Feeling unreal (depersonalization) or that the world is unreal (derealization) Panic can cause severe withdrawal, hallucinations or delusions, and a sense of feeling unreal or feeling that the world is unreal (depersonalization and derealization). A decreased need for sleep, being more talkative than usual or feeling pressure to keep talking, and flight of ideas can occur with bipolar I disorder and do not commonly occur with panic.
Fluoxetine is prescribed for a client with depression. Which precaution will the nurse consider when initiating treatment with this medication? It must be given with milk and crackers to prevent hyperacidity and discomfort. Eating cheese or pickled herring or drinking wine may cause a hypertensive crisis. The blood level may not be sufficient to cause noticeable improvement for 2 to 4 weeks. The blood level should be checked weekly for 3 months to make sure it is appropriate.
The blood level may not be sufficient to cause noticeable improvement for 2 to 4 weeks. Fluoxetine does not produce an immediate effect; nursing measures must be continued to reduce the risk for suicide. Consuming milk and crackers to help prevent hyperacidity and discomfort is not necessary. Avoiding cheese, pickled herring, and wine is a precaution taken with monoamine oxidase inhibitors. Weekly blood level checks are not necessary with fluoxetine.
Which strategy would the nurse employ to be effective when using play therapy with a 6-year-old child with autism? Play music and dance with the child. Use mechanical and inanimate objects for play. Employing positive reinforcements such as hugging. Provide brightly colored toys and blocks that can be held.
Use mechanical and inanimate objects for play. Self-isolation and disinterest in interpersonal relationships lead the autistic child to find security in nonthreatening, impersonal objects. Dancing with the child is too threatening for a child with autism because of the close personal contact it requires. Close interaction, such as hugging, with others is too threatening for a child with autism. These children do not respond to brightly colored toys and blocks as other children do unless movement is involved.
A client with depression was prescribed fluoxetine and reports restlessness, confusion, an elevated body temperature, and poor concentration. Which intervention would the nurse anticipate preparing for in the treatment of these signs and symptoms? Withdrawing the medication Administering isocarboxazid Reducing the dose of the medication Informing the client that these are expected side effects
Withdrawing the medication Restlessness, confusion, poor concentration, and fever are symptoms of serotonin syndrome. The only treatment for serotonin syndrome is discontinuation of the medication. Isocarboxazid is a monoamine oxidase inhibitor that should not be used in a client with serotonin syndrome because it may lead to life-threatening conditions. Reducing the medication dosage may not reverse the symptoms completely. Informing the client that these are expected adverse effects is important, but the medication should be discontinued immediately.
Which behaviors are observed in children with autism? Select all that apply. One, some, or all responses may be correct. Imitates others Engages in cooperative play Avoids eye-to-eye contact Seeks physical contact Performs repetitive activities Prefers children rather than adults
Avoids eye-to-eye contact Performs repetitive activities Impairment of social interaction manifests as a lack of eye contact, a lack of facial responses, and a lack of responsiveness to and interest in others. Children with autism display obsessive ritualistic behaviors such as rocking, spinning, dipping, swaying, toe-walking, head-banging, and hand-biting because of their self-absorption and need to stimulate themselves. The impairments in communication and imaginative activity result in a failure to imitate others and failure to engage in cooperative or imaginative play with others. These children are indifferent to or have an aversion to affection and physical contact. They are unable to establish meaningful relationships with adults or children because of their lack of responsiveness to others.
Which assessment findings would the nurse report to the health care provider as a possible sign of autism in an 18-month-old child? Child clings to mother or father during times of stress and fatigue Child avoids eye contact and does not respond to facial expressions Child cries when the nurse approaches to do the physical examination Child verbalizes using single words with gestures and hand motions
Child avoids eye contact and does not respond to facial expressions Autism impairs bonding, communication, and socialization and typically becomes apparent early in life. Seeking support and comfort from parents during stressful events is normal, as is stranger anxiety. Verbalization of one or two words with gestures would also be considered normal development.
The nurse identifies which medication as used to treat both generalized anxiety disorder and depression? Fluoxetine Bupropion Duloxetine Mirtazapine
Duloxetine Duloxetine is an antidepressant medication used to treat both generalized anxiety disorder and depression. Fluoxetine is used to treat depression. Bupropion is used to treat depression and also aid in smoking cessation. Mirtazapine is used in the treatment of depression and is also helpful in reducing the adverse sexual side effects in the male client receiving selective serotonin reuptake inhibitor therapy.
Which assessment findings are suggestive of postpartum depression? Select all that apply. One, some, or all responses may be correct. Lethargy Ambivalence Emotional lability Increased appetite Long periods of sleep
Lethargy Ambivalence Emotional lability Lethargy reflects the lack of physical and emotional energy that is associated with depression. Ambivalence, the coexistence of contradictory feelings about an object, person, or idea, is associated with postpartum depression. Emotional lability is associated with postpartum depression. Anorexia, rather than increased appetite, is associated with postpartum depression; the client lacks the physical and emotional energy to eat. Insomnia, rather than long periods of sleep, is also associated with postpartum depression.
Which nutrition-related problem would the nurse address when teaching childhood nutrition to a group of parents whose children have Down syndrome? Rickets Obesity Anemia Rumination
Obesity Obesity is a common nutritional problem of children with Down syndrome. It is thought to be related to excessive caloric intake and impaired growth. Rickets is a nutritional disorder related to vitamin D deficiency; it is usually not encountered in these children. Anemia is the most common nutritional problem in children with iron deficiency. Rumination is an eating disorder of infancy characterized by repeated regurgitation without a gastrointestinal illness.
A 15-year-old adolescent with Down syndrome is scheduled for surgery. The parents inform the nurse that their child has a mental age of 8 years. At which age level would the nurse prepare the child's preoperative teaching plan? Adult, for the parents to understand Specific age, as ordered by the health care provider (HCP) Adolescent, because this is the child's chronological age School-age, because this is the child's developmental age
School-age, because this is the child's developmental age A child who is undergoing a procedure needs to be prepared in an easily understood manner; teaching should be directed at the developmental, not chronological, age of this adolescent. The HCP informs the parents about the surgery and its outcomes as a part of informed consent; the nurse may elaborate on this information or correct misinterpretations. It is the nurse's responsibility to prepare the adolescent for the surgery; the HCP may or may not address this need. Information designed for an adolescent will exceed the cognitive ability of a child with the developmental age of 8 years.
A client with obsessive-compulsive disorder (OCD) begins to perform a ritual that involves several complex hand motions, but it is time for the client to go to group therapy. Which intervention is the best choice? Tell the client to stop going to group until the ritual is controlled. Instruct the client to perform the hand motions for the group. Delay the start of the group session until after the ritual is finished. Tell the client to join the group as soon as the ritual is completed.
Tell the client to join the group as soon as the ritual is completed. The purpose of the ritual is to decrease anxiety, so the best choice is to tell the client to join the group as soon as she or he can. This is not ideal; the group norms usually include punctuality. For subsequent sessions the nurse and client would negotiate time for the ritual that did not overlap with the group time. The nurse would not discontinue a therapy without consulting the health care provider and other members of the health care team. Performing the hand motions during the group would be disruptive and distracting to the other group members, and it is likely to increase embarrassment for the client with OCD. Delaying the start of the group is not fair or therapeutic for the other group members.
Which craniofacial characteristics indicate to the nurse that the newborn has fetal alcohol syndrome (FAS)? Select all that apply. One, some, or all responses may be correct. Thin upper lip Wide-open eyes Small upturned nose Larger-than-average head Smooth vertical ridge in the upper lip
Thin upper lip Small upturned nose Smooth vertical ridge in the upper lip The abnormal facial characteristics associated with FAS include a thin upper lip (vermilion), a small upturned nose, and a smooth vertical ridge (philtrum) in the upper lip, all of which are distinctive in these infants. Infants with FAS have small eyes with epicanthic folds, rather than wide-open eyes, and microcephaly (head circumference less than the 10th percentile), rather than a larger-than-average head.
Which instructions would the nurse include in parent teaching for their 6-year-old child with autism spectrum disorder who exhibits frequent spinning and hand-flapping behaviors? Hold the child. Place the child in time-out. Use another activity to distract the child. Determine the reason for the child's behavior.
Use another activity to distract the child. The nurse would instruct the parents to use another activity to distract the child. Providing a constructive distraction will help redirect the autistic child's behavior. Physical contact, such as holding the child, provokes anxiety for the child with autism spectrum disorder. A time-out is punitive and is not constructive. Determining the reason for the child's behavior would be frustrating for the parents because the reason for this repetitive behavior is unknown.
Which behaviors indicate that the interventions used to help a 6-year-old boy with attention-deficit/hyperactivity disorder (ADHD) have been effective? Select all that apply. One, some, or all responses may be correct. Is not inhibited by rules or routines Has fun playing with toys by himself Waits for others to finish speaking Has an increased attention span in school Takes a turn during games with others
Waits for others to finish speaking Has an increased attention span in school Takes a turn during games with others One characteristic of children with ADHD is the inability to remain focused on any activity; an increased attention span in school indicates that the child has improved. Other characteristics of children with ADHD are impulsivity, impatience, and the inability to delay gratification; the ability to wait for others to finish speaking or to take turns indicates that the child has improved. A lack of inhibition by rules or routines indicates that the child has not made sufficient progress and his behavior is still impulsive. Playing by himself indicates that the child has not made progress because children should enjoy playing with peers at this age.
Which response would the nurse make to a client with panic disorder who had a panic attack on the previous day and says, "That was a terrible feeling I had yesterday. I'm so afraid to talk about it"? "Okay; we don't have to talk about it." "Why don't you want to talk about it?" "What were you doing yesterday when you first noticed the feeling?" "I understand, but don't be concerned; that feeling probably won't come back.
"What were you doing yesterday when you first noticed the feeling?" The response, "What were you doing yesterday when you first noticed the feeling?" helps the client focus on a situation that has precipitated anxious feelings. Saying, "Okay; we don't have to talk about it," avoids an opportunity for the nurse to help the client explore feelings. The client may not be able to answer the question, "Why don't you want to talk about it?" The focus should be on feelings and the use of "why" should be avoided. The response, "I understand, but don't be concerned; that feeling probably won't come back," is false reassurance; the nurse cannot guarantee that the feelings will not come back. Unfortunately, these feelings usually reappear with panic attacks.
Which behavior would be typical for a child with autism? Lack of eye contact Crying for attention Catatonia-like rigidity Engaging in parallel play
Lack of eye contact Lack of eye contact is a typical behavior associated with autism. Children with autism usually have a pervasive impairment of reciprocal social interaction. Crying for attention, rigidity, and parallel play are not indicative of autism.
A pregnant client whose first child has Down syndrome is about to undergo amniocentesis. The client tells the nurse that she does not know what she will do if this fetus has the same diagnosis and asks if the nurse thinks that abortion is the same as killing. Which response would the nurse give? "Some people think that that's what an abortion is." "No, I don't think so, but it's your decision to make." "I really can't answer that question. Are you ambivalent about abortion?" "I don't want to answer that question at this time. How do you feel about it?"
"I really can't answer that question. Are you ambivalent about abortion?" The nurse's statement "I really can't answer that question. Are you ambivalent about abortion?" acknowledges that she is unable to answer the question; however, it is open-ended, allowing the client to communicate and reflect more on her own belief system. Stating that some people think that an abortion constitutes killing is judgmental and does not give the client the opportunity to express her feelings. The nurse would not give an opinion on a moral question for a client, because this creates a barrier to the client's own reflection and communication. Declining to answer the question leaves the burden of the decision to the client without offering assistance or the opportunity for further communication.
A child with attention-deficit/hyperactivity disorder (ADHD) is prescribed methylphenidate. The mother asks about its action and side effects. Which response by the nurse is most appropriate? "This medicine increases the appetite." "This medicine must be continued until adulthood." "It is a short-acting medicine that must be given with each meal." "It is a stimulant that has a calming effect on children with ADHD."
"It is a stimulant that has a calming effect on children with ADHD." Although the exact mechanism is unknown, clinical improvements have been reported with sympathomimetic amines such as methylphenidate. After the purpose and action of the medication are explained, the nurse would review side effects with the parent. The appetite of a child taking methylphenidate usually diminishes. The child should be medicated for as short a period as possible. Each child is evaluated individually. The duration of methylphenidate is 3 to 6 hours, or 8 hours with the extended-release form.
A client with depression is prescribed the tricyclic antidepressant imipramine. The client asks the nurse what the medication will do. Which statement by the nurse is appropriate? "It will help you forget why you are depressed." "It will help keep you alert and cure your insomnia." "It will help you feel better after taking it for several days." "It will help you feel better, but make sure to report ideas of self-harm."
"It will help you feel better, but make sure to report ideas of self-harm." This medication creates a general sense of well-being and helps lift depression. It blocks the reuptake of norepinephrine and serotonin into nerve endings, increasing their action in nerve cells. The client might not know the reason for his or her depression, and the medication does not cause amnesia. Side effects of imipramine include drowsiness and insomnia. The information provided does not indicate that the client is experiencing insomnia. Symptomatic relief usually begins after 2 to 3 weeks of therapy.
The nurse is providing care to an infant diagnosed with Down syndrome. Which parental statement related to the infant's growth indicates the need for further education? "My baby will have growth deficiencies during infancy." "My child will have accelerated growth during adolescence." "My child will most likely be overweight by 3 years of age." "My baby will have reduced growth in both height and weight."
"My child will have accelerated growth during adolescence." Children diagnosed with Down syndrome will often have growth deficiencies. These deficiencies are most pronounced during adolescence and infancy. Because weight gain is more rapid than growth in stature, many children with Down syndrome are overweight by 3 years of age. Overall reduced growth is noted for both height and weight.
A client has just given birth to an infant with Down syndrome. The mother is crying and asks the nurse what she is supposed to do now. Which response would the nurse give? "Tell me what you know about Down syndrome." "I would just continue to rest and recover from your delivery." "You really need to pull yourself together for your baby." "Should I call in a chaplain or social worker for you?"
"Tell me what you know about Down syndrome." Asking the client what she knows about Down syndrome is an open-ended question that will facilitate teaching and open dialogue. Telling the client to just recover is not addressing the client's emotional adjustment. Chastising the client for emotional expression will block further dialogue. A chaplain or social worker is not needed at this moment but could potentially be used later.
A depressed client has been prescribed a tricyclic antidepressant. How long does it usually take before the client notices a significant change in the depression? 4 to 6 days 2 to 4 weeks 5 to 6 weeks 12 to 16 hours
2 to 4 weeks It takes 2 to 4 weeks for the tricyclic antidepressant to reach a therapeutic blood level. Time spans of 4 to 6 days and 12 to 16 hours are both too short for a therapeutic blood level of the medication to be achieved. Improvement in depression should be demonstrated sooner than 5 to 6 weeks.
At which age are the signs of autism initially evident? 1 to 3 months 6 months 2 years 6 years
2 years By 2 years of age the child should demonstrate an interest in others, communicate verbally, and possess the ability to learn from the environment. Infantile autism may occur in an infant of 1 to 3 months, but at this age it is difficult to diagnose. Before 2 years when skills develop, autism is difficult to diagnose. Usually by 3 years the signs of autism become more profound. Autism can be diagnosed long before a child is 6 years old.
Which assessment would the nurse prioritize for a newborn with Down syndrome? Reflex responses for hypotonicity Eye examination for congenital cataracts Sensory examination for muscle flaccidity Cardiac irregularities for congenital heart disease
Cardiac irregularities for congenital heart disease Children with Down syndrome have a high incidence of congenital heart defects, indicated by altered heart sounds. Without treatment, a heart defect may become life threatening. The other options are expected but are not life threatening and therefore not prioritized.
Which action would the nurse take for a 6-year-old child with autism spectrum disorder who is nonverbal and makes limited eye contact? Encourage the child to sing songs with the nurse. Engage in parallel play while sitting next to the child. Provide opportunities for the child to play with other children. Use therapeutic holding when the child does not respond to verbal interactions.
Engage in parallel play while sitting next to the child. The nurse would engage in parallel play while sitting next to the child. Entering the child's world in a nonthreatening way by engaging in parallel play while sitting next to the child helps promote trust and eventual interaction with the nurse. Singing songs with the child or providing opportunities for the child to play with other children is unrealistic at this time; playing with others is a long-term objective. Using therapeutic holding may be necessary when a child initiates self-mutilating behavior.
Which prognosis for a normal, productive life would be appropriate for a child with autism spectrum disorder? Dependent on an accurate diagnosis Often related to the child's overall temperament Ensured as long as the child attends a school tailored to meet needs Guarded because of interference with so many parameters of function
Guarded because of interference with so many parameters of function The prognosis is guarded. There are many factors that affect a normal productive life. Accurate diagnosis has not been shown to promote a normal, productive life; however, early, intensive intervention may help individuals maximize their abilities. Although temperament may affect the child's response to treatment, it does not affect prognosis to any extent. Stating that success is ensured as long as the child attends a school tailored to meet needs is false reassurance and is not helpful.
Which actions would the nurse implement to empower a family who has a child with Down syndrome? Select all that apply. One, some, or all responses may be correct. Ask the family to engage in spiritual activities. Help the family recognize the possible stressors. Encourage the use of problem-solving strategies. Encourage more out-of-home activities for the parents. Refer the family to support groups and Internet resources.
Help the family recognize the possible stressors. Encourage the use of problem-solving strategies. Refer the family to support groups and Internet resources.
Which characteristic is commonly seen in children who have autism? Excessive response to any stimulus Normal response to physical contact Lacks response to the environment Limited response due to low intelligence
Lacks response to the environment Poor interpersonal relationships, inappropriate behavior, and learning disabilities prevent autistic children from emotionally adapting or responding to the environment even when the intelligence level is high. It is the lack of response to stimuli that is the clue that the child may have autism. Children with autism have an aversion to physical contact. Low level of intelligence is not a defining characteristic for autistic children.
The nurse is caring for a child who has attention-deficit/hyperactivity disorder (ADHD). Which changes in the child's classroom will be beneficial? Select all that apply. One, some, or all responses may be correct. Providing breaks frequently at regular intervals Writing instructions on the blackboard after verbalization Increasing the number of classroom assignments and homework Improving the writing skills of the child compared with computer skills Scheduling academic subjects for times when the child is under the effect of medication
Providing breaks frequently at regular intervals Writing instructions on the blackboard after verbalization Scheduling academic subjects for times when the child is under the effect of medication A child with ADHD will not be able to concentrate properly and experiences difficulty sitting in one place for a prolonged time. Frequent breaks are helpful to improve the child's concentration. Visual representations also help attract attention and improve concentration. It is appropriate to write instructions after saying them. The child will have increased concentration under the effect of medication, which is generally in the morning. Academic subjects should be scheduled for the morning. A child with ADHD will have dysgraphia, or poor handwriting. It is appropriate to concentrate on improving the child's computer skills, instead of improving handwriting. It is appropriate to allot more time to take tests and help the child complete tasks rather than giving homework and assignments.
Methylphenidate has been prescribed with meals for a child with attention-deficit/hyperactivity disorder (ADHD). Which rationale would the nurse provide for the parents about the timing of the medication administration? Ritalin depresses the appetite. This will ensure proper absorption. It is an oral mucous membrane irritant. Children tend to forget to take it before meals.
Ritalin depresses the appetite. A side effect of methylphenidate is anorexia; it should be given during or immediately after breakfast. The absorption rate is not affected by the timing of when it is given. Oral mucous membrane irritation is not a side effect of methylphenidate. In a child of this age the parents are responsible for administering medications.
Which clinical findings associated with Down syndrome should the nurse expect when performing a physical assessment? Select all that apply. Saddle nose Thin fingers Inner epicanthic folds Transverse palmar crease
Saddle nose Inner epicanthic folds Transverse palmar crease Children with Down syndrome have a broad nose with a depressed bridge ( saddle nose), as well as inner epicanthic folds and oblique palpebral fissures; they also have speckling of the iris (Brushfield spots). Children with Down syndrome have a transverse palmar crease (simian crease) formed by fusion of the proximal and distal palmar creases. These children also have broad, short, stubby hands and feet.
A child who has attention-deficit/hyperactivity disorder (ADHD) is prescribed methylphenidate hydrochloride. Which behavior indicates the child needs further treatment? The child follows instructions given by teachers on a regular basis. The child remains attentive during long classes while seated at a desk. The child experiences difficulty keeping school assignments organized. When instructed to wait, the child sits in one place without complaint.
The child experiences difficulty keeping school assignments organized. A child with ADHD will have difficulty organizing belongings and tasks. The child who has difficulty organizing school assignments even after treatment with methylphenidate hydrochloride will require further treatment. After successful treatment of ADHD, the child will be able to remain attentive for prolonged periods of time. Successful treatment with methylphenidate hydrochloride makes the child more attentive to instructions. The child with ADHD is hyperactive, so he or she does not stay quiet. If the child is obedient and stays quiet, the treatment has been effective.
A client is prescribed the benzodiazepine alprazolam for the management of panic attacks. The nurse is confident that the medication information discussed has been understood when the client takes which action? The client removes the pepperoni from a pizza. The client asks for an extra bottle of flavored water to drink with dinner. The client requests a prescription for oral contraceptives before being discharged. The client states that chewable antacids may be taken to relieve heartburn.
The client requests a prescription for oral contraceptives before being discharged. Benzodiazepines increase the risk of congenital anomalies and so should not be taken by pregnant women. Refraining from eating pepperoni is appropriate for people taking monoamine oxidase inhibitors because tyramine needs to be strictly avoided. Appropriate hydration is critical for those taking lithium. Antacids can affect both absorption and metabolism of benzodiazepines and should be avoided.
List the interventions in order, from the least invasive to the most invasive, for a child with attention-deficit hyperactivity disorder (ADHD) who often becomes frustrated and loses control. Avoid situations that usually precipitate frustration. Monitor behavior for cues of rising anxiety. Use a signal to remind the child to use self-control. Refocus the child's behavior with a specific directive. Place the child in a time-out.
The order from least invasive to most invasive is as follows: (1) avoid situations that usually precipitate frustration, (2) monitor behavior for cues of rising anxiety, (3) use a signal to remind the child to use self-control, (4) refocus the child's behavior with a specific directive, and (5) place the child in a time-out. Situations that promote inattention, hyperactivity, and impulsivity should be avoided. Monitoring behavior for rising anxiety allows the nurse to cue the child to the behavior or to limit environmental stimuli. When cues of increasing frustration are noted, the child should be given a predetermined word, gesture, or eye contact as a reminder to maintain control. When the child is unable to impose self-control, a simple, concrete directive may be used to interrupt and redirect the unacceptable behavior. Strategic removal, such as a time-out, is the most restrictive of the interventions listed.
