The nurse is performing a physical assessment of a 3-year-old girl. What finding would be a concern for the nurse?
The toddler's anterior fontanel is not fully closed.
The toddler gained 3 in in height since last year.
The toddler gained 4 lb in weight since last year.
The circumference of the child's head increased 1 in since last year.
The Correct Answer is A
A. The toddler's anterior fontanel is not fully closeD. The closure of the anterior fontanel typically occurs by around 18 months of age. If the fontanel is still open at 3 years old, it may indicate a delay in normal development and could be a cause for concern. The nurse should further assess this finding and consider follow-up with the healthcare provider.
B. The toddler gained 3 in in height since last year: Growth in height is expected during early childhood, and a gain of 3 inches over a year is within the normal range for a 3-year-old.
C. The toddler gained 4 lb in weight since last year: Weight gain is also expected during early childhood, and a gain of 4 pounds over a year is within the normal range for a 3-year-old.
D. The circumference of the child's head increased 1 in since last year: Head circumference typically increases during early childhood as the brain grows, and a 1-inch increase over a year is within the normal range for a 3-year-old.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "Keep a night light on in your child's room." - This option addresses the child's fear of
monsters by providing a solution that offers comfort and reassurance without dismissing the child's concerns outright.
B. "Let your child sleep in your bed with you." - While this may temporarily alleviate the child's fear, it doesn't address the underlying issue or help the child learn coping mechanisms for dealing with fear.
C. "Tell your child that monsters are not real." - This response invalidates the child's feelings and may increase anxiety by dismissing their fears as irrational.
D. "Stay with your child until the child is asleep." - While staying with the child may provide comfort initially, it doesn't offer a long-term solution and may reinforce the fear by implying that there is something to be afraid of.
Correct Answer is C,A,D,B
Explanation
Correct Answer:C, A, D, B.
C. Inspection:The initial step in an abdominal assessment is to inspect the abdomen visually. This allows the nurse to observe for any abnormalities in skin color, shape, and
movement without causing discomfort or altering findings that could be affected by palpation or auscultation.
A. Auscultation:Following inspection, auscultation is performed before any palpation. This is because palpation can stimulate bowel sounds, which may alter the nurse's ability to accurately assess the bowel activity and vascular sounds.
D. Superficial palpation:After auscultation, superficial palpation is done to detect tenderness, distension, or superficial masses. It is gentle and less likely to cause discomfort or alter deeper structures.
B. Deep palpation: The final step is deep palpation, which is used to examine the organs and structures that are deeper within the abdominal cavity. It is performed last to prevent any potential discomfort or alteration in the patient's condition that could interfere with the earlier steps of the assessment.
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