Which statement by the mother of an 18-month-old would lead the nurse to believe that the child should be referred for further evaluation for developmental delay?
“My child has a vocabulary of approximately 20 words.”
“My child is still thumb sucking.”
“My child seems to be quite wary of strangers.”
“My child is able to stand but is not yet taking steps independently.”
The Correct Answer is D
A. “My child has a vocabulary of approximately 20 words.”
This statement indicates language development, and an 18-month-old with a vocabulary of approximately 20 words is within the expected range. It's a positive indicator of language acquisition.
B. “My child is still thumb sucking.”
Thumb sucking is a common self-soothing behavior in infants and toddlers. While it's a normal behavior, it typically decreases with age. Thumb sucking alone may not necessarily be a cause for concern unless it persists significantly and interferes with other aspects of development.
C. “My child seems to be quite wary of strangers.”
Stranger anxiety is a normal developmental stage, and many children exhibit wariness or fear of unfamiliar people around the age of 18 months. It is considered a typical response and not necessarily indicative of developmental delay.
D. “My child is able to stand but is not yet taking steps independently.”
At 18 months, most children are expected to be walking independently. The inability to take independent steps might be a concern for gross motor skill development. While some variation is normal, a delay in achieving this milestone might prompt further evaluation to rule out any underlying developmental issues.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Sore throat:
A sore throat is a common symptom of various respiratory tract infections, including acute epiglottitis. However, examining the throat with a tongue depressor is unlikely to directly precipitate a sore throat in this context.
B. Complete obstruction:
Examining the child's throat with a tongue depressor in acute epiglottitis can potentially trigger spasm or swelling of the already inflamed epiglottis, leading to a rapid and complete obstruction of the airway. This is a critical concern and is why healthcare providers approach suspected cases of epiglottitis with great caution.
C. Inspiratory stridor:
Inspiratory stridor (high-pitched sound during inhalation) is a common symptom of upper airway obstruction, including in conditions like acute epiglottitis. It may be present without manipulation, but using a tongue depressor in the throat could exacerbate this symptom.
D. Respiratory tract infection:
Acute epiglottitis is indeed a type of respiratory tract infection. However, examining the throat with a tongue depressor is not likely to directly precipitate a respiratory tract infection.
Correct Answer is A
Explanation
A. Preventing spread of infection:
This is a priority because individuals with acquired immunodeficiency syndrome (AIDS) have a compromised immune system. Preventing the spread of infections is crucial to avoid additional complications and safeguard the individual's health.
B. Maintaining skin integrity:
Skin integrity is important for overall health, but in the context of AIDS, preventing infections and promoting immune function take precedence over maintaining skin integrity. Skin issues might be secondary to the immune system's compromised state.
C. Improving nutrition:
Good nutrition is important for overall health, including supporting the immune system. However, preventing the spread of infection is more immediate and critical in the case of someone with AIDS. Addressing nutritional needs can be part of the overall care plan but might be secondary to preventing infections.
D. Promoting comfort:
While promoting comfort is essential in nursing care, the priority in the case of a child with AIDS would be preventing the spread of infection due to the immunocompromised state. Comfort measures may be incorporated into the care plan, but they would not take precedence over preventing further health complications.
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