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. A child who is brought to the emergency room with labored breathing: Labored breathing can indicate a serious respiratory problem that requires immediate assessment and intervention.
Conducting a comprehensive health history is crucial to gather information about the child's medical history, current symptoms, and any potential underlying conditions that could be contributing to the breathing difficulty.
B. A child who is a new client in a pediatric officE. While it is important to obtain a comprehensive health history for new clients in a pediatric office, it may not require immediate attention unless the child presents with acute symptoms or concerns.
C. A child who is a routine client and presents with signs of a sinus infection: While a child presenting with signs of a sinus infection may require a comprehensive health history to guide treatment, it may not necessitate immediate attention unless the symptoms are severe or accompanied by complications.
D. A child whose condition is improving: If a child's condition is improving, conducting a comprehensive health history may not be immediately necessary unless there are lingering concerns or new symptoms that arise during follow-up visits.
Correct Answer is ["C","D","E"]
Explanation
A. Use mummy restraints during painful procedures: Using restraints may increase the child's anxiety and resistance, exacerbating the fear of procedures. It is important to minimize any factors that may increase the child's distress during procedures.
B. Perform the procedure as quickly as possiblE. While it is important to minimize the duration of procedures to reduce discomfort, rushing the procedure excessively may increase the child's
anxiety and make the experience more traumatic. A balance should be struck between efficiency and ensuring the child feels comfortable and secure.
C. Have a parent stay with the child during procedures: Having a familiar caregiver present can provide comfort and reassurance to the child during procedures. The presence of a parent can help the child feel safe and supported, reducing anxiety and fear.
D. Cluster invasive procedures whenever possiblE. Clustering invasive procedures minimizes the frequency of painful experiences for the child, reducing overall distress and anxiety. This approach also allows the child to have longer periods of comfort between procedures.
E. Allow the child to keep a toy from home with her: Providing a familiar toy or comfort item can serve as a distraction and source of comfort for the child during procedures. Allowing the child to hold onto something familiar can help reduce anxiety and provide a sense of security.
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