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A nurse is collecting data from an 18-month-old toddler. Which of the following findings should the nurse report to the provider?

Speaks four words

Builds a tower of three blocks

Has temper tantrums

Jumps in place with both feet

Answer and Explanation

The Correct Answer is A

Choice A reason:

At 18 months, a toddler should typically be saying more than four words. This finding may

indicate a potential delay in speech development, and it should be reported to the provider for further evaluation.

Choice B reason:

Building a tower of three blocks is an appropriate developmental milestone for an 18-month-old and does not warrant reporting.

Choice C reason:

Temper tantrums are a normal behavior for toddlers, as they are still developing emotional regulation skills. This finding does not require reporting unless it is severe or causing harm to the child.

Choice D reason:

Jumping in place with both feet is an appropriate developmental milestone for an 18-month-old and does not warrant reporting.

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Correct Answer is C

Explanation

Choice A reason:

Reducing fiber intake is not necessary for a client in skeletal traction. Maintaining a balanced diet, including fiber, is important for overall health.

Choice B reason:

The nurse should not lift the traction weights off the floor. The weights must hang freely to provide the necessary traction.

Choice C reason:

Performing passive range-of-motion exercises helps prevent stiffness and muscle atrophy in the affected extremity. This is an important nursing intervention for a client in skeletal traction.

Choice D reason:

Applying protective padding to the pin sites is essential to prevent pressure and irritation. However, this action alone does not address the need for range-of-motion exercises.

A. Apply cold compresses to painful joints. B. Maintain bed rest to prevent hypoxemia. C. Decrease daily oral fluid intake. D. Administer meperidine to eliminate a fever.

Correct Answer is B

Explanation

Choice A reason:

Cold compresses may exacerbate vaso-occlusion in a client with sickle cell anemia and are not recommended.

Choice B reason:

Maintaining bed rest can help reduce the risk of hypoxemia, as it minimizes energy expenditure and oxygen demand.

Choice C reason:

Increasing oral fluid intake is important for preventing vaso-occlusive crises, so decreasing fluid intake is not a recommended intervention.

Choice D reason:

Administering meperidine for fever is not a standard intervention for sickle cell anemia. Fever during a vaso-occlusive crisis should be evaluated and treated according to the underlying cause.

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A nurse is collecting data from an 18-month-old toddler. Which of the following findings should the nurse report to the provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the care of an adolescent client who is in skeletal traction for the treatment of a fractured femur. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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