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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

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. Report sudden, persistent headaches. – Correct. Persistent headaches may indicate a stroke, a severe complication of sickle cell anemia due to vaso-occlusion.

B. Restrict fluid intake during times of stress. – Incorrect. Hydration is crucial to prevent sickling of red blood cells. Fluids should be increased, not restricted.

C. Apply cold compresses to painful areas. – Incorrect. Cold can cause vasoconstriction and worsen sickling. Warm compresses are recommended instead.

D. Avoid meningococcal immunizations. – Incorrect. Children with sickle cell anemia are at increased risk for infections and should receive all recommended vaccinations, including the meningococcal vaccine.

A. Place the client on an air mattress. B. Rewrap the bandage every 8 hr in a circular pattern. C. Turn the client every 4 hr while in bed. D. Instruct the client to use an overbed trapeze to move around in bed.

Correct Answer is D

Explanation

A. Place the client on an air mattress – While air mattresses help prevent pressure ulcers, they do not directly address mobility needs in the immediate postoperative period.

B. Rewrap the bandage every 8 hr in a circular pattern – The bandage should be reapplied more frequently (every 4–6 hr) using a figure-eight pattern to prevent restriction of circulation.

C. Turn the client every 4 hr while in bed – Clients should be turned at least every 2 hr to prevent pressure ulcers and improve circulation.

D. Instruct the client to use an overbed trapeze to move around in bed – This is the best intervention because it allows the client to reposition independently, reducing the risk of skin breakdown and enhancing mobility.

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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?

Nursing Test Bank

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