A child with autism spectrum disorder (ASD) is admitted to the hospital with pneumonia. The nurse would plan which priority intervention when caring for the child?

Correct Answer: D

Rationale: The correct answer is D) Maintain a structured routine and keep stimulation to a minimum. In caring for a child with autism spectrum disorder (ASD) admitted to the hospital with pneumonia, maintaining a structured routine and minimizing stimulation is crucial. Children with ASD often have sensory sensitivities and may become overwhelmed in new or stimulating environments, which can exacerbate their symptoms and distress. By providing a structured routine and minimizing stimulation, the nurse can create a calming and predictable environment for the child, promoting comfort and facilitating recovery. Option A) Placing the child in a room with a roommate of the same age may increase sensory input and disrupt the child's routine, leading to distress and potential worsening of symptoms. Option B) Taking the child frequently to the playroom to play with other children can overwhelm the child with social interactions and sensory stimuli, which can be challenging for a child with ASD and may hinder recovery. Option C) Maintaining frequent touch and eye contact with the child may not be appropriate as children with ASD can be sensitive to touch and eye contact, which can cause discomfort and distress. Educationally, understanding the unique needs of children with ASD is essential for nurses caring for them in various healthcare settings. Providing a supportive and accommodating environment tailored to the individual needs of each child with ASD is critical in promoting their well-being and ensuring effective care delivery.

Correct Answer: D

Rationale: In this scenario, the correct response is option D: "Scratching the lesions may cause them to become secondarily infected." This answer is correct because when a child scratches the areas where they have bed bugs, it can lead to breaks in the skin, creating openings for bacteria to enter and cause a secondary infection. This is a common concern in pediatric patients with skin conditions exacerbated by scratching. Option A is incorrect because scratching can indeed cause problems such as skin breakdown and infection. Option B is incorrect as bed bug bites can cause itching due to the body's reaction to the bug's saliva. Option C is incorrect as scratching the lesions will not cause the bed bugs to spread; however, it can lead to complications like infection. In an educational context, it is crucial for nurses to understand the implications of scratching on skin integrity, especially in pediatric patients. Teaching parents about the risks associated with scratching can help prevent further complications and promote proper wound care practices. Nurses play a vital role in educating families on how to manage skin conditions effectively to prevent secondary infections and promote healing.

Correct Answer: C

Rationale: In pediatric respiratory assessment, understanding the role of Vitamin A supplementation in specific childhood diseases is crucial. The correct answer is C) Measles (rubeola). Measles can lead to Vitamin A deficiency due to increased utilization, malabsorption, and decreased intake during the illness. Vitamin A supplementation is recommended to prevent complications such as blindness and death in children with measles. Option A) Erythema infectiosum, commonly known as Fifth disease, does not specifically warrant Vitamin A supplementation. Option B) Mumps and Option D) Rubella also do not typically necessitate Vitamin A supplementation as part of their management. Educationally, this question highlights the importance of understanding the nutritional considerations in pediatric illnesses, especially respiratory conditions like measles. Nurses need to be aware of the indications for Vitamin A supplementation in certain diseases to provide optimal care and prevent complications in pediatric patients. By linking Vitamin A deficiency to measles, this question reinforces the importance of holistic care in pediatric respiratory assessment.

Correct Answer: B

Rationale: The correct answer is B) An opportunity for regression. In the context of a hospitalized preschool child in isolation, it is developmentally appropriate for children of this age to regress when faced with stress or changes in their environment. Isolation can disrupt their routine, causing them to revert to behaviors from an earlier stage of development as a way to cope with the unfamiliar situation. This regression can manifest as clinginess, bedwetting, or seeking more comfort from caregivers. Option A) Loss of companionship with friends may cause distress, but it is not the most expected reaction in this scenario. Preschoolers are more focused on their immediate environment and caregivers. Option C) A threat to the child's self-image is more relevant to older children who have a more developed sense of self. Preschoolers are still in the process of forming their self-concept. Option D) Seeing isolation as a punishment requires a higher level of cognitive understanding and may be more common in older children who can link their behavior to consequences. Educationally, understanding typical responses of preschoolers to stressors like hospitalization and isolation is crucial for pediatric nurses to provide appropriate care and support. Recognizing regression as a common coping mechanism can help nurses tailor their approach to meet the child's emotional needs effectively.

Correct Answer: B

Rationale: The most appropriate nursing action when a parent reports that their child has a temperature of 101°F (38.3°C) is to encourage the child to rest and increase fluid intake, which is option B. This response aligns with the initial management of a low-grade fever in a child. Encouraging rest helps the body conserve energy to fight off the infection causing the fever, while increasing fluid intake helps prevent dehydration, which is common with fevers. By following this approach, the child's body can better regulate its temperature and aid in the recovery process. Option A is not the best choice as waiting for 24 hours without taking any action may lead to the child's condition worsening if there is an underlying infection. Administering acetaminophen (Option C) should only be done if the child is uncomfortable or if the fever is high. Suggesting a visit to the emergency department (Option D) is premature for a low-grade fever without any other concerning symptoms. Educationally, it is crucial for nurses to understand the initial management of fevers in pediatric patients. Teaching parents about home care measures can empower them to support their child's recovery and know when further medical intervention is necessary. It is essential for nurses to provide evidence-based guidance to promote the well-being of pediatric patients.