A nurse is collecting data from a 3-year-old child. Which of the following developmental milestones should the nurse expect the child to demonstrate?
Uses four words in a sentence
Ties shoelaces
Skips on alternate feet
Names the days of the week
The Correct Answer is A
Choice A reason:
Using four words in a sentence is an appropriate developmental milestone for a 3-year-old child. By this age, children typically have a vocabulary that allows them to form short sentences and express themselves.
Choice B reason:
Tying shoelaces is a fine motor skill that is typically developed later, around 5-6 years of age.
Choice C reason:
Skipping on alternate feet is a gross motor skill that is typically developed around 4-5 years of age.
Choice D reason:
Naming the days of the week is a cognitive skill that is typically developed later, around 5-6 years of age. It involves not only memory but also an understanding of the concept of days and their order.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason:
Muehrcke lines on the nails are associated with certain medical conditions but are not indicative of acute glomerulonephritis.
Choice B reason:
Correct. Hypertension is a common manifestation of acute glomerulonephritis due to the impaired filtration function of the kidneys.
Choice C reason:
Dehydration is not a typical manifestation of acute glomerulonephritis. Instead, fluid retention and edema are more common.
Choice D reason:
Hypokalemia (low potassium levels) is not a typical finding in acute glomerulonephritis. Instead, hyperkalemia (high potassium levels) may occur.
Correct Answer is B
Explanation
A: Suctioning the client's airway every 2 hours is not indicated based on the provided information. The adolescent does not have a condition that compromises airway clearance, and routine suctioning can cause trauma or stimulate a vagal response, potentially leading to bradycardia.
B: Maintaining the client's head of the bed at 30° is appropriate for reducing intracranial pressure and facilitating venous drainage. The patient's symptoms of nuchal rigidity and severe headache suggest increased intracranial pressure, possibly due to meningitis, which is supported by the diagnostic results.
C: Keeping the client's room well lit is not advisable as the patient reports photophobia, which is a sensitivity to light. A well-lit room could exacerbate discomfort and pain.
D: Checking the client's temperature every 8 hours is important but not the priority intervention. The patient's condition requires more frequent monitoring due to the positive blood culture and sensitivity, indicating an active infection. More frequent temperature checks would be warranted.
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