A nurse is assessing a 3-year-old child and suspects the child may have a developmental delay. Which of the following actions is a priority for the nurse to take?
Discuss the assessment findings with the primary care provider.
Utilize social work for referral to early intervention.
Provide the parents with pamphlets for support groups for children with developmental delays.
Educate the parents on the developmental delays their child is diagnosed with.
The Correct Answer is A
A. The priority is to discuss the findings with the primary care provider to determine the next steps in diagnosis and intervention. Early identification and referral are crucial for addressing developmental delays.
B. Referring to early intervention is important but should follow the discussion with the primary care provider to ensure an appropriate and coordinated response.
C. Providing pamphlets is supportive but secondary to initiating a formal evaluation and intervention process.
D. Educating the parents is essential, but it should be based on a confirmed diagnosis and plan developed in collaboration with healthcare providers.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Respiratory rate can be affected by many factors and is not the most reliable indicator of fluid loss.
B. Body weight is the most reliable indicator of fluid loss, as it directly reflects changes in body fluid levels.
C. Blood pressure changes can occur with fluid loss but may not be as sensitive or immediate as changes in body weight.
D. Skin integrity is important to monitor, but changes in body weight provide a more direct measure of fluid status.
Correct Answer is D
Explanation
A. A bulging fontanel indicates increased intracranial pressure or fluid overload, not dehydration. With dehydration, you expect a sunken fontanel.
B. Bradypnea (slow breathing) is not typically associated with dehydration and may indicate other issues.
C. A capillary refill time of 3 seconds suggests delayed perfusion, but it is not as indicative of severe dehydration as other signs.
D. Severity of dehydration is classified by percentage of body weight lost:Severe: ≥10% loss, moderate: 6–9% loss, mild: 3–5% loss. A 13% loss = severe dehydration, which matches the scenario.
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