A nurse is collecting data from an 18-month-old toddler at a well-child visit.
Which of the following findings should the nurse report to the provider?
The toddler can remove her own socks.
The toddler has a security blanket.
The toddler can say four words.
The toddler throws a ball without falling.
The Correct Answer is C
c. The toddler can say four words.
Explanation:
The nurse should report to the provider that the toddler can say four words. At 18 months, a toddler typically has a vocabulary of about 6 to 20 words and is beginning to combine words into simple phrases. If the toddler is only able to say four words or has a delay in language development, it could be a cause for concern and warrant further evaluation.
The other options are age-appropriate developmental milestones for an 18-month-old toddler and do not require immediate reporting to the provider. The ability to remove socks, having a security blanket, and throwing a ball without falling are all examples of normal developmental skills for a toddler of this age.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
c. "I will have a chest x-ray following the procedure."
Explanation:
The statement that indicates an understanding of the information provided is "I will have a chest x-ray following the procedure."
Explanation for the other options:
a. "I will have general anesthesia during the procedure":
This statement is incorrect. Thoracentesis is typically performed using local anesthesia, which numbs the area where the needle will be inserted. General anesthesia, which induces a state of unconsciousness, is not usually required for this procedure.
b. "I will lie flat for 6 hours following the procedure":
This statement is incorrect. While the client may be advised to lie still for a short period after the thoracentesis, it is not necessary for them to lie flat for a full 6 hours. The specific post-procedure instructions may vary depending on the client's condition and the healthcare provider's preferences.
d. "I will breathe deeply through my nose during the procedure":
This statement is incorrect. During a thoracentesis, the client is typically asked to sit upright and lean forward to allow beter access to the space between the lungs and chest wall. They may be instructed to take slow, deep breaths and hold their breath for short periods as needed during the procedure to help maintain proper positioning and reduce the risk of complications.
In summary, the statement that demonstrates an understanding of the thoracentesis procedure is "I will have a chest x-ray following the procedure." This indicates the client's awareness of the need for a post- procedure chest x-ray to evaluate the results and ensure the absence of any complications.
Correct Answer is B
Explanation
b. Monitor the client for 15 min after meals.
Explanation:
The correct answer is b. Monitor the client for 15 min after meals.
Anorexia nervosa is a serious eating disorder characterized by self-imposed starvation and a distorted body image. When planning care for a client with anorexia nervosa, it is important to focus on interventions that promote safety, nutritional rehabilitation, and psychological support.
Option a is not the correct answer. Encouraging the client to gain 2.3 kg (5 lb) per week is not a realistic or healthy goal for weight gain in the context of anorexia nervosa. Rapid weight gain can be physically and psychologically overwhelming for the client and may reinforce disordered eating behaviors.
Option c is not the correct answer. Weighing the client each morning after voiding may contribute to obsessive monitoring of weight, which is a common feature of anorexia nervosa. Frequent weigh-ins can exacerbate anxiety and fixation on numbers, which are detrimental to the client's recovery.
Option d is not the correct answer. Reinforcing teaching about healthy eating during meals is not an appropriate intervention for a client with anorexia nervosa. Anorexia nervosa involves a distorted perception of body weight and shape, as well as deeply ingrained beliefs and fears related to food. Focusing on teaching about healthy eating during meals may trigger anxiety and reinforce disordered thoughts and behaviors.
By recommending the intervention to monitor the client for 15 minutes after meals, the nurse ensures close observation during a critical time when the client may engage in compensatory behaviors such as purging or exercising excessively. This intervention allows for immediate identification of any concerning behaviors and provides an opportunity for therapeutic intervention, support, and redirection.
It is crucial to approach care for clients with anorexia nervosa with sensitivity and an understanding of the complex psychological and physiological challenges they face. The chosen intervention focuses on the immediate post-meal period and aims to promote safety and support the client in their recovery journey.
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