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 B
Explanation
Rationale:
A. Call the nurse who made the error to discuss the medication error – This is not the appropriate action. The focus should be on client safety and proper reporting, not on discussing the error with the previous nurse.
B. File an incident report within 24 hr – This is the correct action. Incident reports should be completed promptly to document the error and ensure proper follow-up.
C. Notify the facility's pharmacist within 1 hr of the incident – While the pharmacist may be informed if a medication reversal or adjustment is needed, this is not the primary action to take.
D. Place an incident report in the client’s medical record – Incident reports are internal documents and should not be placed in the medical record to avoid legal concerns.
Correct Answer is A
Explanation
A. Heart rate 148/min – Correct. A heart rate of 148/min in a 3-year-old is elevated (tachycardia) and may indicate worsening dehydration or shock.
B. Potassium 3.9 mEq/L – Incorrect. This potassium level is within the normal range (3.5–5.0 mEq/L).
C. Respiratory rate 22/min – Incorrect. This is within the expected range for a 3-year-old.
D. Sodium 142 mEq/L – Incorrect. This sodium level is within the normal range (135–145 mEq/L).
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