A nurse is assessing a 2-year-old toddler. Which of the following findings should the nurse expect?

Natural loss of deciduous teeth

Nontender, protruding abdomen

Palpable fontanels

Head circumference exceeds chest circumference

Answer and Explanation

The Correct Answer is B

A.   Incorrect. The natural loss of deciduous (baby) teeth typically begins around 6 years of age, not at 2 years old.
B.   Correct. Toddlers often have a nontender, protruding abdomen due to their underdeveloped abdominal muscles.
C.   Incorrect. The fontanels (soft spots on the baby's head) should be closed by 18-24 months of age. Palpable fontanels at 2 years old could indicate abnormal cranial development.
D.   Incorrect. It is not typical for a 2-year-old's head circumference to exceed their chest circumference. Head circumference is usually greater in infants but gradually becomes similar to chest circumference by 1-2 years of age.

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Correct Answer is C

Explanation

Choice A rationale:

Hearing loss is not a typical sign of digoxin toxicity. Digoxin toxicity primarily affects the visual system, leading to disturbances such as blurred or yellow-tinted vision. It can also cause various cardiac symptoms due to its effects on heart rhythm and contractility. Hearing loss is not a recognized symptom of digoxin toxicity.

Choice B rationale:

Tachycardia (fast heart rate) can be a sign of digoxin toxicity. Digoxin can cause arrhythmias and alter heart rate, which may lead to tachycardia. While this is a possible symptom, it is not as specific as other manifestations, such as visual disturbances.

Choice C rationale:

Blurred vision is a hallmark sign of digoxin toxicity. Digoxin can cause disturbances in color vision, such as seeing yellow or green halos around objects. Blurred vision is a significant indicator of digoxin toxicity and requires prompt medical attention.

Choice D rationale:

Insomnia is not a recognized symptom of digoxin toxicity. Digoxin toxicity primarily affects the cardiovascular and visual systems, leading to symptoms related to heart rhythm disturbances and vision changes. Insomnia is not a typical manifestation of digoxin toxicity.

A. Talk with the client during her feeding. B. Discourage the client from coughing during feedings. C. Sit at or below the client's eye level during feedings. D. Instruct the client to lift her chin when swallowing.

Correct Answer is C

Explanation

A. Incorrect. While it's important to maintain social interaction with the client, avoiding excessive conversation during feeding is recommended. Distractions can interfere with the client's ability to focus on swallowing and increase the risk of aspiration.

B. Incorrect.Coughing is a natural reflex that helps to clear the airway of any material that may have been aspirated. Discouraging coughing could potentially lead to a more serious problem.

C. Correct.Sitting at or below the client's eye level provides a clearer view of the food and helps the client maintain control over their swallowing. This can reduce the risk of aspiration.

D. Incorrect.Lifting the chin can actually increase the risk of aspiration by narrowing the opening to the trachea (windpipe). It's generally recommended to avoid lifting the chin during swallowing.

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A nurse is assessing a 2-year-old toddler. Which of the following findings should the nurse expect?

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Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who is taking digoxin to treat chronic heart failure.Which of the following findings should indicate to the nurse that the client is developing digoxin toxicity?

Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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Select the 4 findings that require follow-up.

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