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A nurse is assessing a 24-month-old toddler at a well-child checkup. Which of the following findings indicates to the nurse that the toddler has a developmental delay?

Falls when throwing a ball overhand

Goes up stairs with two feet on each step

Runs with a wide stance

Refers to self by name

Answer and Explanation

The Correct Answer is D

A. It is expected for a 24-month-old to have some difficulty with coordination when throwing a ball.

B. Using both feet on each step when going upstairs is developmentally appropriate at this age.

C. Running with a wide stance is common in toddlers as they develop balance and coordination.

D. This is the correct answer. By 24 months, a toddler should begin using pronouns such as "I" or "me" instead of referring to themselves by name, indicating a possible language delay.

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Correct Answer is A

Explanation

A. Vital signs should be monitored every 15 minutes because naloxone has a short duration and the client may experience opioid re-sedation as the antagonist wears off.

B. Naloxone should be administered over 2 minutes, not 15 seconds, to reduce abrupt opioid withdrawal symptoms.

C. Naloxone has a rapid onset (1-2 minutes IV, 2-5 minutes IM).

D. The effects of naloxone last only 30-90 minutes, requiring repeated doses if opioids are still in the system.

A. Shake both insulin vials for 2 min before withdrawing the doses. B. Administer the mixture within 5 min of preparing it. C. Withdraw the NPH insulin before the regular insulin. D. Inject air into the regular insulin vial before injecting air into the NPH vial.

Correct Answer is B

Explanation

A. Insulin vials should not be shaken because this can create air bubbles, leading to inaccurate dosing. Instead, NPH insulin should be gently rolled between the palms to evenly mix the suspension. Regular insulin does not require mixing.

B. Once regular and NPH insulin are mixed, they should be administered promptly to maintain their stability and effectiveness. Delaying administration may alter insulin absorption, leading to unpredictable glucose control.

C. Regular insulin should be drawn up before NPH insulin to prevent contaminating the clear regular insulin with the cloudy NPH insulin. The correct order is to inject air into the NPH vial first (without withdrawing insulin), then inject air into the regular insulin vial, withdraw the regular insulin, and finally withdraw the NPH insulin.

D. The correct technique is to first inject air into the NPH vial, then inject air into the regular insulin vial. This prevents contamination and maintains sterility. However, when withdrawing insulin, regular insulin is drawn first to prevent mixing of NPH insulin into the regular insulin vial.

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A nurse is assessing a 24-month-old toddler at a well-child checkup. Which of the following findings indicates to the nurse that the toddler has a developmental delay?

Nursing Test Bank

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