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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Incorrect. While the nurse is curious about the client's reasons, it may come across as intrusive or defensive.
B. Incorrect. Making an assumption about the client's potential benefit is not appropriate. The client has the right to access their own records.
C. Correct. This response is respectful of the client's request while also explaining the limitation related to therapist notes.
D. Incorrect. The about the client's happiness with treatment is not directly related to their request for therapist notes.
Correct Answer is B
Explanation
Choice B rationale:
Flumazenil is a selective antagonist for the benzodiazepine receptor and is used as an antidote for benzodiazepine toxicity. It competitively inhibits the effects of benzodiazepines by binding to the same receptor sites in the central nervous system. Flumazenil can rapidly reverse the sedative and respiratory-depressant effects of benzodiazepine overdose, making it the appropriate choice in this scenario.
Choice A rationale:
Atropine is an anticholinergic medication that is used to treat bradycardia and certain types of heart block. It has no specific antidote effects for benzodiazepine toxicity and would not be the appropriate choice in this situation.
Choice C rationale:
Activated charcoal is used in the management of certain types of poisonings by adsorbing the toxic substance in the gastrointestinal tract, preventing its absorption into the bloodstream. However, it is not effective for benzodiazepine toxicity, which primarily affects the central nervous system and not the gastrointestinal tract.
Choice D rationale:
Naloxone is an opioid receptor antagonist used to reverse opioid overdose. It has no specific effects on benzodiazepine toxicity and would not be the appropriate choice in this case.
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