A nurse is assessing a 2-year-old toddler. Which of the following findings should the nurse expect?

Natural loss of deciduous teeth

Nontender, protruding abdomen

Palpable fontanels

Head circumference exceeds chest circumference

Answer and Explanation

The Correct Answer is B

A.   Incorrect. The natural loss of deciduous (baby) teeth typically begins around 6 years of age, not at 2 years old.
B.   Correct. Toddlers often have a nontender, protruding abdomen due to their underdeveloped abdominal muscles.
C.   Incorrect. The fontanels (soft spots on the baby's head) should be closed by 18-24 months of age. Palpable fontanels at 2 years old could indicate abnormal cranial development.
D.   Incorrect. It is not typical for a 2-year-old's head circumference to exceed their chest circumference. Head circumference is usually greater in infants but gradually becomes similar to chest circumference by 1-2 years of age.

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Correct Answer is D

Explanation

A. Opioid medications can cause constipation, and increasing fluid intake helps prevent dehydration and promotes bowel regularity. However, it does not directly prevent cosntipation.

B. Incorrect. While some laxatives or stool softeners might be recommended, mineral oil is generally not recommended due to its potential to interfere with the absorption of fat-soluble vitamins.

C. Incorrect. Increasing insoluble fiber intake, rather than decreasing it, can help prevent constipation.

D. Increasing exercise is key in preventing constipation caused by opiod analgesics

A. Encourage the client to lie down in a quiet room. B. Refer to the hallucinations as if they are real. C. Avoid eye contact with the client. D. Ask the client directly what he is hearing.

Correct Answer is D

Explanation

A. Incorrect. Encouraging the client to lie down in a quiet room is not specifically related to addressing auditory hallucinations.
B. Incorrect. Referring to hallucinations as if they are real can reinforce the client's delusions or hallucinations.
C. Incorrect. Avoiding eye contact can be perceived as dismissive or uninterested.
D. Correct. Asking the client directly about their hallucinations helps assess their content and severity, which is essential for developing an effective plan of care.

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A nurse is assessing a 2-year-old toddler. Which of the following findings should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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