A nurse in a provider's office is assessing the motor skill development of a 15-month-old toddler during a well-child visit. Which of the following gross motor skills should the nurse expect?
Takes several steps on tip toes
Walks without assistance using a wide stance
Has an accentuated cervical curvature when standing
Stands with the feet turned slightly inward
The Correct Answer is B
A. Takes several steps on tiptoes. Typically develops around 24 months, not 15 months.
B. Walks without assistance using a wide stance. At 15 months, toddlers typically walk independently with a wide stance to improve balance.
C. Has an accentuated cervical curvature when standing. Not an expected motor milestone.
D. Stands with the feet turned slightly inward. Inward foot positioning can indicate a developmental delay or foot abnormality.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Report the finding to the provider. While the provider should be informed if the hypertension is new, persistent, or symptomatic, the nurse should first verify the blood pressure before escalating the concern.
B. Compare the finding to the client's blood pressure baseline. Checking the baseline is important, but the first action should be to confirm the accuracy of the reading by rechecking it. If the reading is consistent with previous values, the nurse can then compare it to the baseline.
C. Administer antihypertensive medications as prescribed. Administering medication without confirming the blood pressure reading could lead to unnecessary treatment or hypotension if the reading was inaccurate. The nurse should first recheck the BP.
D. Recheck the client's blood pressure. Rechecking the blood pressure ensures accuracy before making clinical decisions. Factors such as incorrect cuff size, client positioning, or transient increases (e.g., anxiety or pain) could cause an elevated reading. If the elevated BP is confirmed, then further action (e.g., notifying the provider or administering medication) can be taken.
Correct Answer is C
Explanation
A. Limit the use of hand gestures when communicating with the client. Hand gestures enhance communication for clients with hearing loss. Visual cues such as gestures, facial expressions, and lip reading can help improve understanding.
B. Speak to the client with an increased pitch. Speaking in an increased pitch is not recommended because higher frequencies are often harder for clients with hearing loss to detect. Instead, the nurse should speak clearly, slowly, and in a lower tone.
C. Use written materials to assist with communication. Written materials help clients with hearing loss understand important information, especially if they rely on lip reading or have significant hearing impairment.
D. Limit visitors to avoid communication misunderstandings. Limiting visitors is unnecessary and may lead to social isolation. Instead, the nurse should encourage communication using appropriate strategies, such as writing or sign language.
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