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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Jaw pain in a client taking alendronate, a bisphosphonate, for postmenopausal osteoporosis may be a sign of a rare but serious side effect called osteonecrosis of the jaw (ONJ). Therefore, the nurse should respond by: Report the client's jaw pain to the healthcare provider.

Jaw pain can be an indication of ONJ, a condition characterized by the death of jawbone tissue. It is important to notify the healthcare provider so that further evaluation and appropriate management can be initiated. The healthcare provider will determine the best course of action, which may include referral to a specialist for further assessment and treatment.

Determining how the client is administering the medication is not the immediate concern in this situation. While it is important to ensure that the client is following proper administration instructions for alendronate, addressing the jaw pain takes precedence. Advising the client to gargle with warm salt water twice daily may not be sufficient or appropriate for managing jaw pain related to alendronate use. The client needs a comprehensive assessment by the healthcare provider to determine the cause of the jaw pain and provide appropriate interventions.

Confirming that jaw pain is a common symptom of osteoporosis is not accurate. While osteoporosis can lead to bone pain, jaw pain specifically associated with bisphosphonate use is more likely to be related to ONJ and requires further evaluation and management.

A. Administer a cathartic suppository 30 min prior to scheduled defecation times. B. Encourage a maximum fluid intake of 1,500 mL per day. C. Increase the amount of refined grains in the client's diet. D. Provide the client with a cold drink prior to defecation.

Correct Answer is A

Explanation

A. Correct. Administering a cathartic suppository can help stimulate bowel movement and facilitate a bowel-training program, particularly for individuals with altered bowel function due to spinal cord injury.

B. Incorrect. Adequate fluid intake is important, but limiting fluid intake is not typically recommended for clients with spinal cord injuries.

C. Incorrect. Refined grains are not specifically indicated for promoting bowel function. A balanced diet with sufficient fiber is more appropriate.

D. Incorrect. Providing a cold drink prior to defecation might not have a significant impact on bowel function and is not a commonly recommended intervention.

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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 developmental delay?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A female client is taking alendronate, a bisphosphonate, for postmenopausal osteoporosis. The client tells the nurse that she is experiencing jaw pain. How should the nurse respond?

Correct Answer is C

Explanation

A nurse is planning care for a client who has a prescription for a bowel-training program following a spinal cord injury. Which of the following actions should the nurse include in the plan of care?

Correct Answer is A

Explanation

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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 developmental delay?