A nurse is assessing a 24-month-old toddler at a well-child checkup. Which of the following findings indicates to the nurse that the toddler has a developmental delay?
Falls when throwing a ball overhand
Goes up stairs with two feet on each step
Runs with a wide stance
Refers to self by name
The Correct Answer is D
A. It is expected for a 24-month-old to have some difficulty with coordination when throwing a ball.
B. Using both feet on each step when going upstairs is developmentally appropriate at this age.
C. Running with a wide stance is common in toddlers as they develop balance and coordination.
D. This is the correct answer. By 24 months, a toddler should begin using pronouns such as "I" or "me" instead of referring to themselves by name, indicating a possible language delay.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Temperature: 37.2°C (99.0°F) is within the normal range.
B. Respiratory rate: 28/min is elevated but expected in COPD.
C. An SpO₂ of 88% indicates significant hypoxemia in a client with COPD, which requires immediate intervention. Oxygen therapy may be needed to maintain a target saturation of 88–92%.
D. pH: 7.22 indicates respiratory acidosis but is consistent with COPD and requires monitoring rather than immediate notification.
Correct Answer is C
Explanation
A. Nylon socks should be avoided as they do not allow moisture to escape, which can promote fungal infections.
B. Toenails should be trimmed straight across rather than rounded to prevent ingrown toenails, which can lead to infections.
C. This is the correct answer. Clients with peripheral vascular disease (PVD) should use lamb’s wool between toes that rub together to prevent pressure ulcers and skin breakdown.
D. Compression stockings can be harmful in PVD if not prescribed by a provider because they may impair circulation further.
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