A nurse is assessing a 2-year-old child at a well-child visit. The child's parent expresses concern about the child's increasing temper tantrums and difficult behaviors. Which of the following statements should the nurse respond with?
"Diets can play a part in behavioral concerns. What does your child typically eat during the day?"
"Discipline is an important aspect of parenting. How do you discipline the child when they act out?"
"Toddlers are beginning to develop a desire for autonomy. Temper tantrums are normal during this stage."
"Some children have more difficult personalities. There are great parenting books that can help you."
The Correct Answer is C
A. While diet can influence behavior, the concern here is the child’s developmental stage, making this response less relevant.
B. Discussing discipline is important, but understanding normal developmental behaviors is more appropriate in this context.
C. Explaining that temper tantrums are normal for toddlers, who are starting to develop a sense of autonomy, helps reassure the parent that this behavior is typical and part of the child's development.
D. Suggesting parenting books might be helpful, but it does not directly address the parent's immediate concern about the behavior.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. This site is used most often to obtain a pulse in infants during CPR or blood pressure measurement, but it does not provide the most accurate heart rate assessment.
B. The radial artery is not typically used in infants because it is less accessible and not as easily palpated in this age group.
C. The apical pulse (measured with a stethoscope at the 4th intercostal space, left midclavicular line) is the most accurate site for infants and children under 2 years old. It directly reflects the heart’s activity and is less affected by peripheral perfusion.
D. The carotid artery is not typically used for assessing the heart rate in infants due to the risk of applying excessive pressure.
Correct Answer is B
Explanation
A. These vital signs are generally within expected ranges for a 2-year-old child.
B. A blood pressure of 79/40 mm Hg is low for a 2-year-old, and the elevated heart rate of 135/min and increased respirations suggest that the child may be experiencing significant distress or volume depletion, requiring immediate attention.
C. These vital signs are within normal limits for a 2-year-old child.
D. Although the blood pressure is on the lower end of normal and heart rate is slightly elevated, these findings are less concerning than option B.
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