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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. "Symptoms of Lyme disease appear 2 days after being bitten by an infected tick." – Incorrect. Symptoms of Lyme disease typically develop 3 to 30 days after a tick bite, not within 2 days.
B. "If bitten by a tick, testing for Lyme disease should occur within 2 weeks." – Incorrect. Testing immediately or within two weeks may yield a false-negative result because antibodies take time to develop. The CDC recommends waiting 4 to 6 weeks for accurate testing.
C. "Use a product with DEET on your skin and clothes when you are walking in a wooded area." – Correct. DEET is an effective tick repellent and should be applied to exposed skin and clothing to reduce the risk of tick bites, which can transmit Lyme disease.
D. "Remove embedded ticks by squeezing the body with tweezers." – Incorrect. The proper method for tick removal is to grasp it close to the skin with fine-tipped tweezers and pull straight out. Squeezing the tick’s body can cause it to release infectious fluids into the bite site, increasing the risk of disease transmission.
Correct Answer is A
Explanation
A. "I will make sure that we respect your right to refuse medications." – This response respects the client's autonomy and reassures them that their rights will be upheld.
B. "You will need to rest so that you can recover from the episode that brought you here." – This statement dismisses the client's concerns rather than addressing them.
C. "Why do you think your provider will prescribe you medications that will make you sleep?" – While open-ended questions can encourage discussion, this does not directly reassure the client about their rights.
D. "It's not your choice to be here, so you have to accept the treatment we plan for you." – This statement is inappropriate and disregards the client's legal rights.
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