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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:
Ensuring the child's safety is the top priority. If the child is in immediate danger, steps must be taken to protect them.
Choice B reason:
While providing emotional support to the child is important, ensuring their physical safety takes precedence.
Choice C reason:
Documenting injuries is important for a comprehensive assessment and for legal purposes, but it should follow ensuring the child's immediate safety.
Choice D reason:
Notifying law enforcement may be necessary, but ensuring the child's immediate safety comes first.
Correct Answer is C
Explanation
Choice A reason:
Increased alertness may be a sign of improved glucose levels, but it is not as direct an indicator as a blood glucose measurement.
Choice B reason:
Diaphoresis is a symptom of low blood glucose levels and indicates the need for intervention rather than effectiveness of therapy.
Choice C reason:
A blood glucose level of 50 mg/dL is within the normal range and indicates that the glucagon therapy has been effective in raising blood glucose levels.
Choice D reason:
The presence of urine ketones indicates that the body is using fats for energy, which may occur in the absence of adequate glucose. This is not an indicator of the effectiveness of glucagon therapy.
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