A nurse assessing a 3-year toddler at a well-child visit. Which of the following manifestations should the nurse report to the provider?

Weight 14.5 kg (32 lb)

Respiratory rate 45/min

Blood pressure 90/50 mm Hg

Heart rate 110/min

Answer and Explanation

The Correct Answer is B

A. A weight of 14.5 kg (32 lb) is normal for a 3-year-old.

B. A respiratory rate of 45 breaths per minute is elevated for a 3-year-old, whose normal range is 20-30 breaths per minute.

C. A blood pressure of 90/50 mm Hg is normal for a toddler.

D. A heart rate of 110/min is within the expected range for a 3-year-old.

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Correct Answer is []

Explanation

Potential Condition: Child maltreatment

Actions to take:

Interview the child separately from the parents

Ask a parent, away from the child

Parameters to monitor:

Signs of fear or apprehension from the child when either parent is present

Negative comments about child from either parent.

Rationale:

Potential Condition: Child Maltreatment

The client’s history of multiple injuries (bloody nose, sutures from hitting cabinet, and spiral fracture) in the context of the parent’s alcohol intoxication, slurring, and aggressive behavior raises concern for possible child maltreatment. The child’s statement about being "clumsy" and the observed scars also support the need for further investigation into possible abuse.

Actions to Take

Interview the child separately from the parents: To ensure the child can speak freely and report any concerns without the influence or presence of the parents, especially when maltreatment is suspected.

Ask a parent, away from the child: The parent should be interviewed privately to assess their behavior and any possible stressors or issues that could indicate abuse or neglect, especially considering their appearance and actions when visiting the child.

Parameters to Monitor

Signs of fear or apprehension from the child when either parent is present: This could indicate emotional distress or fear related to the parent’s behavior. It is important to observe how the child reacts to the presence of each parent during assessments.

Negative comments about the child from either parent: Verbal abuse or negative comments can be a red flag for emotional abuse or neglect. Careful attention should be paid to any signs of verbal maltreatment.

Potential Diagnoses: Incorrect Choices

Muscular Dystrophy: While this could explain a pattern of injury due to muscle weakness, it does not align with the history of multiple injuries caused by trauma or the current family dynamics.

Constipation: No evidence or symptoms supporting constipation were observed in the current assessment.

Strabismus: No direct evidence to suggest strabismus in the child’s history or exam.

A. Duchenne muscular dystrophy usually improves as the child gets older. B. Speech and vision may be impaired and inhibit communication. C. Cognitive impairment can improve with intensive therapy. D. Mobility concerns usually arise later in adulthood.

Correct Answer is B

Explanation

A. Duchenne muscular dystrophy is a progressive condition that worsens over time, leading to increasing disability.

B. Children with DMD may experience speech and vision impairments as part of the disease process, which could affect communication.

C. Cognitive impairment is often a feature of DMD, but it does not typically improve with therapy. It is a progressive issue.

D. Mobility concerns in DMD begin in childhood, not adulthood, as the muscles weaken and deterioration progresses.

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A nurse assessing a 3-year toddler at a well-child visit. Which of the following manifestations should the nurse report to the provider?

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Naxlex Comprehensive Predictor Exams

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Correct Answer is []

Explanation

A nurse is creating a plan of care for a pediatric client who has been diagnosed with Duchenne muscular dystrophy (DMD). Which of the following factors should the nurse consider when planning care?

Correct Answer is B

Explanation

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