A nurse is collecting data from a 4-year-old child during a well-child visit. Which of the following findings should the nurse expect?
Positive Babinski sign.
Birth height has doubled.
Birth weight has doubled.
Presence of permanent teeth.
The Correct Answer is C
Birth weight has doubled.
Choice A reason:
The nurse should not expect a positive Babinski sign in a 4-year-old child during a well-child visit. The Babinski sign is a reflex seen in infants up to about 1 year of age and disappears as the nervous system matures. Its presence in a 4-year-old would be abnormal and may indicate neurological issues.
Choice B reason:
The nurse should not expect birth height to double in a 4-year-old child during a well-child visit. While children do experience significant growth in their early years, it is unlikely that birth height will have doubled by the age of 4. Doubling of birth height would be an atypical finding.
Choice C reason:
The correct choice. The nurse should expect that the child's birth weight has doubled during a well-child visit. From birth to age 4, children typically experience substantial weight gain, and doubling of birth weight is a common milestone in healthy development.
Choice D reason:
The nurse should not expect the presence of permanent teeth in a 4-year-old child during a well-child visit. Permanent teeth typically begin to emerge around 6 years of age and continue to erupt over the following years. The appearance of permanent teeth at age 4 would be premature and unusual.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason:
The WBC count of 10,000/mm is within the normal range, indicating a normal white blood cell count. There is no cause for concern, and the nurse does not need to report this result to the provider.
Choice B reason:
The Hgb level of 6.8 g/dL is significantly below the normal range, which indicates severe anemia. Menorrhagia, or heavy menstrual bleeding, could be a potential cause of this low hemoglobin level. Anemia can lead to various complications, including fatigue, weakness, and decreased oxygen delivery to tissues. This result requires immediate attention, and the nurse should promptly report it to the healthcare provider for further evaluation and management.
Choice C reason:
The Creatinine level of 0.8 mg/dL is within the normal range. Creatinine is a marker of kidney function, and a normal value suggests that the kidneys are functioning adequately. Since the result is normal, the nurse does not need to report this to the provider.
Choice D reason:
The Potassium level of 3.5 mEq/L is within the normal range, indicating a normal potassium level. There is no immediate concern with this result, and the nurse does not need to report it to the provider.
Correct Answer is A
Explanation
The nurse should maintain continuous observation of the adolescent.
Choice A reason:
The first and most crucial action when a patient expresses an intention to self-harm is to ensure their safety. By maintaining continuous observation, the nurse can closely monitor the adolescent's behavior and intervene promptly if any signs of self-harm emerge. This action helps prevent immediate harm and allows for timely interventions.
Choice B reason:
Applying wrist restraints to the adolescent (Choice B) would not be appropriate in this situation. Restraints are typically used as a last resort for patients who pose a danger to themselves or others and only when less restrictive measures have failed. In the case of self- harm, using restraints can increase the patient's distress and potentially worsen the situation.
Choice C reason:
Collecting data about the adolescent's mental status (Choice C) is an essential step in understanding their overall condition, but it should not be the first action taken. While gathering data is important for a comprehensive assessment, immediate safety concerns must take precedence.
Choice D reason:
Obtaining consent from the adolescent's guardian for the application of restraints (Choice D) is not the first priority when the patient expresses an intention to self-harm. The focus should be on ensuring the patient's immediate safety, and consent for restraints may be necessary only if other interventions prove inadequate.
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