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 developmental delay?
Runs with a wide stance.
Falls when throwing a ball overhand.
Refers to self by name.
Goes up stairs with two feet on each step.
The Correct Answer is B
Choice A rationale:
A toddler running with a wide stance is a common behavior at this age and does not necessarily indicate developmental delay. Toddlers often develop a wide base of support as they learn to balance and walk more confidently.
Choice B rationale:
Falling when throwing a ball overhand requires coordination and motor skills. By the age of 24 months, most toddlers can throw a ball with some degree of accuracy. Inability to do so may indicate a developmental delay in motor skills, making choice B the correct answer.
Choice C rationale:
Referring to oneself by name is a typical language development milestone around the age of 24 months. It demonstrates a basic understanding of self-identity and language, indicating appropriate developmental progress. This choice does not suggest a delay.
Choice D rationale:
Going up stairs with two feet on each step is a gross motor skill that toddlers typically develop around 36 months of age. It requires balance and coordination. While it is advanced for a 24-month-old, it is not necessarily a sign of developmental delay. Therefore, this choice does not provide a clear indication of delay.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Looping the tubing so that it is lower than the collection bag creates a dependent loop where urine can pool, increasing the risk of UTI. This practice should be avoided as it can lead to bacterial contamination and subsequent infections.
Choice B rationale:
Keeping the urinary bag at bladder level when ambulating helps maintain a continuous flow of urine into the collection bag without creating dependent loops. This practice minimizes the risk of bacterial contamination and reduces the chances of acquiring a UTI.
Choice C rationale:
Obtaining urinary samples by disconnecting the tubing connections is not recommended. This procedure can introduce bacteria into the urinary system, increasing the risk of UTI. Sterile techniques, such as using a catheter port for sampling, should be followed to minimize the risk of infection.
Choice D rationale:
Securing the catheter to the client's thigh is essential to prevent tension and pulling on the catheter, which can cause trauma to the urethra. However, securing the catheter alone does not minimize the risk of UTI. Proper hygiene, closed drainage system, and maintaining a continuous flow of urine into the collection bag are key factors in preventing UTIs in clients with indwelling urinary catheters.
Correct Answer is C
Explanation
Based on the client's sudden right-sided numbness, weakness of the arm and leg, and distinct right-sided facial droop, the nurse should suspect a possible stroke and prioritize immediate interventions. After reporting the findings to the healthcare provider and receiving prescriptions, the nurse should implement the following intervention:
Notify the stroke team to assist with acute assessment and management. A stroke is a medical emergency that requires urgent intervention and specialized care. The stroke team is trained to quickly assess and manage stroke patients, including performing necessary diagnostic tests and initiating appropriate treatment. In this case, a STAT computerized tomography (CT) scan of the head has been ordered, indicating the need to evaluate the client's brain for possible ischemic or hemorrhagic stroke.
While keeping the bed in the lowest position and initiating seizure and fall precautions may be important considerations for stroke patients, notifying the stroke team takes precedence as they are specifically trained to manage acute stroke cases.
Administering aspirin to prevent further clot formation and platelet clumping is not appropriate without further assessment and confirmation of the type of stroke.
Additionally, testing for a swallowing reflex and performing communication deficit assessments can be important components of the overall stroke management plan, but they should be carried out by the stroke team or as directed by the healthcare provider.
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