A mother brings a 23-month-old child for a well-child check. She apologizes, stating, “It’s my allergies, not a cold, that is causing me to sniffle so much.” The mother reports that the toddler seems “slower at doing things” than her older children did. The nurse notices that the child sits in the mother’s lap without fear or hesitation and responds to the mother’s questions, but fails to look at the mother’s face when being spoken to. These behaviors are supportive of what additional assessment?
Indications of physical abuse of the child by the caregiver.
Evidence of cocaine abuse by the caregiver affecting the child.
Autistic behaviors demonstrated by the child.
Attention deficit hyperactive disorder (ADHD) characteristics demonstrated by the child.
The Correct Answer is C
Choice A reason: Lack of eye contact and developmental delay don’t directly indicate physical abuse, which typically shows fear or physical signs. Autistic behaviors like poor eye contact are more likely, making this incorrect, as the toddler’s behaviors align better with autism in the well-child assessment.
Choice B reason: Cocaine abuse by the caregiver might affect development but isn’t linked to specific behaviors like poor eye contact. Autistic traits better explain the toddler’s symptoms, making this speculative and incorrect compared to the nurse’s assessment of developmental concerns in the child.
Choice C reason: Poor eye contact and slower development at 23 months suggest autistic behaviors, common in autism spectrum disorder. This aligns with pediatric developmental screening, making it the correct additional assessment for the nurse to consider based on the toddler’s observed behaviors during the check.
Choice D reason: ADHD typically presents later with hyperactivity and inattention, not poor eye contact or developmental delay at 23 months. Autistic behaviors are more fitting, making this incorrect, as the toddler’s symptoms align better with autism than ADHD in the well-child evaluation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Removing equipment reduces clutter but is less urgent than preventing falls, especially post-procedure when a child may be disoriented. Ensuring side rails and a low bed prioritizes safety, making this secondary and incorrect for the most immediate action in pediatric post-procedure care.
Choice B reason: Handling contaminated linens follows infection control but is not the immediate safety concern post-procedure. Preventing falls with side rails and a low bed is critical, making this less urgent and incorrect compared to the priority of ensuring the child’s physical safety after the procedure.
Choice C reason: Assessing side rails up and bed lowered prevents falls, the most immediate safety risk post-procedure when a child may be sedated or unsteady. This aligns with pediatric safety protocols, making it the correct statement for the most urgent action in post-procedure interventions.
Choice D reason: Documentation is essential but not immediate compared to fall prevention, which protects the child post-procedure. Side rails and bed positioning take precedence, making this subsequent and incorrect for the most urgent safety action required after a pediatric procedure in the hospital.
Correct Answer is A
Explanation
Choice A reason: Burn fluid replacement follows the Parkland formula, with half the total volume (24 ounces = 12 ounces) given in the first 8 hours. From 10:00 AM to 6:00 PM (8 hours), the child receives 12 ounces, aligning with pediatric burn care protocols, making this the correct choice.
Choice B reason: By 4:00 PM (6 hours), the child receives less than half the 24 ounces, as half (12 ounces) is given over 8 hours. The 12-ounce mark is reached by 6:00 PM, making this incorrect, as it overestimates fluid delivery in the shorter timeframe for burn treatment.
Choice C reason: 18 ounces by 4:00 PM (6 hours) exceeds the standard rate, as only half (12 ounces) of 24 ounces is given in 8 hours. The correct amount is 12 ounces by 6:00 PM, making this incorrect for burn fluid replacement timing in the pediatric patient’s treatment.
Choice D reason: 18 ounces by 6:00 PM (8 hours) is incorrect, as only half the total (12 ounces) is administered in the first 8 hours per burn protocols. The correct volume is 12 ounces, making this incorrect for the standard fluid replacement schedule in pediatric burn care.
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