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 developmental delay?

Runs with a wide stance.

Falls when throwing a ball overhand.

Refers to self by name.

Goes up stairs with two feet on each step.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

A toddler running with a wide stance is a common behavior at this age and does not necessarily indicate developmental delay. Toddlers often develop a wide base of support as they learn to balance and walk more confidently.

Choice B rationale:

Falling when throwing a ball overhand requires coordination and motor skills. By the age of 24 months, most toddlers can throw a ball with some degree of accuracy. Inability to do so may indicate a developmental delay in motor skills, making choice B the correct answer.

Choice C rationale:

Referring to oneself by name is a typical language development milestone around the age of 24 months. It demonstrates a basic understanding of self-identity and language, indicating appropriate developmental progress. This choice does not suggest a delay.

Choice D rationale:

Going up stairs with two feet on each step is a gross motor skill that toddlers typically develop around 36 months of age. It requires balance and coordination. While it is advanced for a 24-month-old, it is not necessarily a sign of developmental delay. Therefore, this choice does not provide a clear indication of delay.

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Correct Answer is D

Explanation

A. The balloon port is used to inflate or deflate the catheter balloon and is not used for obtaining urine specimens.
B. Unclamping the collection port could contaminate the specimen with non-sterile urine from the tubing.
C. Disconnecting the catheter from the collection tubing could introduce contaminants into the catheter and tubing.
D. Correct. The retention port is a sterile access point on the catheter itself, and it can be used to obtain a sterile urine specimen without compromising the sterility of the collection system.

A. Weight B. Report of cough C. Blood pressure D. Travel history E. Sputum characteristics F. Temperature G. Heart Rate

Correct Answer is ["A","D","E","F","G"]

Explanation

Based on the information provided, the nurse should consider the following client findings for further evaluation:

A. Weight: The client's weight loss of 5 pounds (2.26 kg) over the last week needs further evaluation as it could be indicative of an underlying health issue.

D. Travel history: The client's recent travel to South Africa and the presence of respiratory symptoms raises concerns about possible exposure to infectious diseases, including tuberculosis, which is more prevalent in certain regions. Further evaluation of the travel history is essential.

E. Sputum characteristics: The client's report of "blood-tinged sputum" is concerning and should be evaluated further to rule out potential serious respiratory conditions.

F. Temperature: The presence of a "low-grade fever" should be further evaluated to assess the possible infectious etiology of the client's symptoms.

G. Heart Rate: The heart rate should be assessed further as an elevated heart rate could indicate an underlying systemic infection or other health issues.

The following client findings do not necessarily indicate the need for further evaluation in this context:

B. Report of cough: The client's report of a cough is the primary reason for their presentation to the emergency department and will, of course, be further evaluated as part of the assessment.

C. Blood pressure: Though monitoring blood pressure is essential, the information provided does not indicate any specific concerns regarding the client's blood pressure at this point.

A comprehensive assessment and further evaluation are necessary to determine the underlying cause of the client's symptoms. The nurse should collaborate with other healthcare professionals to conduct appropriate diagnostic tests and investigations to establish a diagnosis and provide appropriate care.

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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 developmental delay?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has an indwelling urinary catheter. The nurse notes that sediment is present in the urine. Which of the following actions should the nurse take to obtain a sterile urine specimen?

Correct Answer is D

Explanation

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Correct Answer is ["A","D","E","F","G"]

Explanation

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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 developmental delay?