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Autism Spectrum Disorder and Down Syndrome (18 Questions)
1. Mme Gagnon brings her 18-month-old son, Léo, to the clinic for a routine check-up. She expresses concern, stating: "My neighbor's son is the same age and is already saying 10 words, but Léo doesn't speak yet. He just sits in the corner and spins the wheels of his toy truck for hours."
Question:
During your assessment of Léo, which specific observation would be considered a significant "red flag" for Autism Spectrum Disorder requiring further evaluation?
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Léo cries loudly when the nurse approaches him with a stethoscope.
Léo has not yet started walking independently.
Léo grabs the toy truck possessively when another child tries to take it.
Léo does not make eye contact or look at the object when his mother points and says, "Look at the ball."
2. Émile, a 6-year-old with Autism Spectrum Disorder, is admitted to the pediatric unit for a scheduled tonsillectomy. Upon admission, he becomes extremely agitated, screaming and flapping his hands. His mother explains, "He is terrified because this is not his bedroom."
Question:
What is the most appropriate nursing intervention to reduce Émile’s distress?
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Ask the mother to leave the room so Émile can bond with the nursing staff.
Consult the parents about his specific daily home routine and try to replicate it as closely as possible in the hospital.
Administer a PRN sedative immediately to ensure he remains calm before surgery.
Turn on the television to a loud cartoon channel to distract him.
3. You are attempting to administer medication to Lucas, a 5-year-old with Autism. When you ask him, "Lucas, do you want to take your juice now?" he responds by saying, "Lucas, do you want to take your juice now?" in the exact same tone.
Question:
How should the nurse interpret this communication?
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Lucas is being defiant and mocking the nurse.
Lucas is deaf and is repeating the vibration he felt.
Lucas is using echolalia, which is his way of attempting to communicate.
Lucas has fully understood the command and is agreeing to take the juice.
4. Sophie, a 9-year-old with severe Autism, is in the emergency department waiting room for a laceration on her arm. The waiting room is crowded, noisy, and the fluorescent lights are flickering. Sophie begins to bang her head rhythmically against the wall and moan.
Question:
What is the priority nursing action?
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Firmly restrain Sophie’s hands to stop her from hurting herself.
Tell the parents to discipline Sophie for acting out in public.
Assess the laceration while she is banging her head.
Immediately move Sophie and her parents to a quiet, dimly lit private room.
5. Marc, 7 years old, is non-verbal and has Autism. He is 4 hours post-operative from an appendectomy. He is rocking back and forth in bed and grimacing, but he does not cry or point to his stomach. His heart rate is 110 bpm. The order reads: "Morphine IV PRN for pain."
Question:
Which assessment tool or method is best to determine if Marc requires analgesia?
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Ask Marc to rate his pain on a scale of 0 to 10.
Assume that because he is not crying, he is not in pain.
Use the FLACC scale and observe for behavioral changes.
Ask the mother if she thinks he needs Tylenol.
6. Mme Roy consults the nurse because her 4-year-old son Thomas (ASD) will only eat beige foods (chicken nuggets, crackers, plain pasta) and refuses to touch anything with a "slimey" texture like fruit or yogurt. She is worried about his nutrition.
Question:
What is the most appropriate initial nursing advice?
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"Starve him for a day; when he gets hungry enough, he will eat whatever you serve."
"Force him to take one bite of the new food before he can leave the table."
"This is food selectivity related to sensory texture aversion; introduce new foods slowly on a separate plate without pressure."
"Blend all his meals into a smoothie so he doesn't notice the texture."
7. Hugo, a 12-year-old with Autism, has been prescribed Risperidone by the psychiatrist to manage severe aggression and self-injury. The parents ask, "What side effects should we watch out for?"
Question:
Which potential adverse effect requires careful monitoring with this medication?
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Severe weight loss and anorexia.
Metabolic changes, including significant weight gain and hyperglycemia.
Hyperactivity and insomnia.
Respiratory depression.
8. Mme Tremblay breaks down crying during a clinic visit for her 10-year-old son with severe ASD. She says, "I haven't slept through the night in 10 years. He wanders if I don't lock the doors. My husband and I are fighting constantly. I just can't do this anymore."
Question:
What is the priority nursing intervention for the family?
*
Refer the mother to a psychiatrist for anti-depressants.
Discuss the option of permanent institutionalization for the child.
Assess the need for respite care services and refer to the social worker/CLSC.
Teach the mother better locking mechanisms for the doors.
9. You are performing a physical assessment on Baby Bouchard, born 2 hours ago. The physician suspects Trisomy 21 (Down Syndrome). The baby is resting quietly in the bassinet.
Question:
Which cluster of physical findings would the nurse identify as consistent with this diagnosis?
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Hypertonia (stiffness), high-pitched cry, and clenched fists.
Cleft lip, polydactyly (extra fingers), and micropthalmia (small eyes).
Webbed neck, wide-spaced nipples, and edema of the hands/feet.
Hypotonia (poor muscle tone), a single transverse palmar crease (Simian crease), and low-set ears.
10. Clara, a 2-month-old infant with Down Syndrome, visits the clinic for a weight check. The mother reports, "She takes a very long time to finish her bottle, and she gets sweaty on her forehead when she drinks." You note that Clara has not gained weight since the last visit.
Question:
Based on the diagnosis of Down Syndrome, which underlying condition does the nurse suspect?
*
Pyloric Stenosis.
Congenital Heart Defect.
Gastroesophageal Reflux.
Hypothyroidism.
11. Hugo, a 12-year-old with Down Syndrome, tells the school nurse he wants to join the gymnastics team and do somersaults and trampolining.
Question:
Before clearing Hugo for these specific activities, what medical screening is essential?
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An ECG to check for arrhythmias.
A vision test for cataracts.
A cervical spine X-ray to rule out Atlantoaxial Instability.
A hearing test.
12. Mme Lefebvre asks why her 3-year-old son with Down Syndrome seems to get pneumonia and ear infections "every single winter," whereas her other children do not.
Question:
What is the best physiological explanation the nurse can provide?
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"Children with Down Syndrome have smaller airways, underdeveloped nasal bones, and lower muscle tone, which makes clearing mucus difficult."
"The extra chromosome prevents antibiotics from working effectively."
"He likely has undiagnosed cystic fibrosis, which is common in Down Syndrome."
"It is because you are not dressing him warmly enough."
13. Liam, a 6-year-old admitted for dehydration secondary to gastroenteritis, has Autism Spectrum Disorder. During the admission interview, his parents explicitly stated, "He has a severe sensory aversion to green foods. If he sees anything green on his plate, he will scream and refuse to eat anything at all." It is lunchtime, and the dietary aide brings a tray containing grilled chicken, mashed potatoes, and steamed broccoli.
Question:
What is the nurse’s priority action before presenting the tray to Liam?
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Present the tray as is, but instruct Liam that he only has to eat the chicken and potatoes.
Remove the broccoli from the tray entirely outside the room, ensuring no green residue remains, before bringing the food to Liam.
Sit with Liam and use positive reinforcement to encourage him to try one bite of the broccoli for nutrition.
Blend the broccoli into the mashed potatoes so he gets the vitamins without seeing the green color.
14.1 Émile, an 8-year-old with Autism, is admitted for observation after a minor fall. His parents inform you that his strict home routine involves lights out and falling asleep exactly at 19:30. Any disruption to this routine causes severe meltdowns and insomnia. You review his medication administration record (MAR) and notice the physician has prescribed: "Melatonin 3 mg PO daily at 20:00."
Question:
What is the most appropriate nursing action?
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Wake Émile up at 20:00 to administer the medication as ordered.
Administer the medication at 19:30 just before he goes to sleep.
Contact the physician to request the administration time be changed to 18:30 or 19:00.
Hold the dose for tonight since he will already be asleep.
14.2 Following the adjustment of the medication time, Émile receives his first dose of Melatonin in the hospital. The next morning, you are performing your assessment.
Question:
Which specific side effect of Melatonin should the nurse monitor for, which could impact Émile’s safety during the day?
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Respiratory depression and low oxygen saturation.
Morning drowsiness, "grogginess," or dizziness.
Hyperactivity and impulsive aggression.
Elevated blood pressure and tachycardia.
15. Sophie, a 5-year-old with severe Autism, is being admitted for pneumonia. She is non-verbal and visibly terrified. Her father asks, "Can she sleep with her giant Squishmallow plushie? It’s the only thing that calms her down, but I know hospitals are strict about germs."
Question:
How should the nurse respond to support Sophie’s mental health?
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"I’m sorry, but large stuffed animals harbor bacteria and are not allowed in the hospital bed."
"She can have it, but you must wrap it in a plastic bag so it doesn't touch the hospital sheets."
"She can only look at it from across the room, but she cannot hold it while she has an IV."
"Yes, absolutely. Having her comfort object is essential for her coping and will help reduce her anxiety during admission."
16. Marc, a 10-year-old with Autism, becomes overwhelmed by the noise of the IV pump alarm. He starts rocking violently and banging his forehead repeatedly against the metal side rail of the hospital bed.
Question:
What is the priority nursing intervention to ensure physical safety?
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Immediately administer a STAT dose of IM Lorazepam.
Shout "No, Marc, stop!" loudly to snap him out of the behavior.
Place a pillow or a blanket between Marc’s head and the metal rail to cushion the impact.
Apply 4-point restraints to the bed frame.
17. You need to obtain a set of vital signs (blood pressure and temperature) from Lucas, a 7-year-old with Autism. He is verbal but processes information slowly.
Question:
Which communication strategy is most effective for obtaining his cooperation?
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"Lucas, it is very important for your health that we check your cardiovascular status, so please sit still."
Use a picture board to show him the cuff and the thermometer, and use short, direct phrases like: "First arm check, then ear check."
Ask him, "Would you like to have your blood pressure taken now, or would you prefer later?"
Approach him silently from behind and put the cuff on quickly so he doesn't have time to react.