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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 D

Explanation

A. Watery stool is not a typical sign of paralytic ileus; instead, bowel sounds are absent or hypoactive.

B. Oliguria (low urine output) is not directly related to paralytic ileus.

C. Dizziness is not a primary symptom of paralytic ileus.

D. This is the correct answer. Abdominal distention occurs due to the accumulation of gas and fluid in the intestines, which are unable to move due to ileus.

A. A client who had a right hemisphere stroke B. A client who had dialysis and is using an arteriovenous shunt in the left lower forearm C. A client who had blood drawn from the right antecubital area 1 hr ago D. A client who has a right peripherally inserted central catheter

Correct Answer is D

Explanation

A. A client who had a right hemisphere stroke – While a stroke may cause weakness on one side, BP measurements can still be taken unless there are additional contraindications like lymphedema or a fistula.

B. A client who had dialysis and is using an arteriovenous shunt in the left lower forearm – BP should never be taken on the arm with an AV shunt, but this does not mean the right arm is unavailable.

C. A client who had blood drawn from the right antecubital area 1 hr ago – Blood draws do not typically affect BP measurements significantly unless there is excessive bruising or infiltration.

D. A client who has a right peripherally inserted central catheter (PICC) – Correct. Blood pressure cuffs can cause compression on the PICC line, leading to catheter occlusion, displacement, or thrombosis. The nurse should instruct the AP to use the opposite arm.

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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

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who is postoperative following orthopedic surgery. Which of the following findings should the nurse identify as an indication of paralytic ileus?

Correct Answer is D

Explanation

A nurse is observing an assistive personnel (AP) measure blood pressures from the right arms of a group of clients. The nurse should instruct the AP to measure the blood pressure in the left arm of which of the following clients?

Correct Answer is D

Explanation

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