A nurse is assessing a 24- month -old toddler.
Which of the following finding should the nurse report to the provider?
Has a vocabulary of 30 words.
Sleep 11 to 12 hr. per day.
Eats a large amount of food one day then very little the next
Holds his breath when having a temper tantrum.
The Correct Answer is D
Choice A rationale
Having a vocabulary of 30 words is not a finding that should be reported to the provider for a 24-month-old toddler. By 24 months, most children can say 50 words or more.
Choice B rationale
Sleeping 11 to 12 hours per day is not a finding that should be reported to the provider for a 24-month-old toddler. This is a typical amount of sleep for a child this age.
Choice C rationale
Eating a large amount of food one day then very little the next is not a finding that should be reported to the provider for a 24-month-old toddler. Toddlers often have variable appetites, and it’s normal for them to eat more on some days and less on others.
Choice D rationale
Holding his breath when having a temper tantrum is a finding that should be reported to the provider for a 24-month-old toddler. While breath-holding spells can be a normal part of toddler behavior, they can also be a sign of an underlying medical condition. It’s important for the provider to evaluate this behavior to rule out any potential health concerns.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Tachypnea, or rapid breathing, is a common clinical manifestation of heart failure in children. This occurs because the heart is unable to pump enough blood to meet the body’s needs, causing fluid to back up into the
lungs and leading to shortness of breath and rapid breathing.
Choice B rationale
Contrary to increased appetite, children with heart failure often experience a decrease in appetite or difficulty feeding. This is due to increased energy expenditure and early satiety caused by abdominal distension from hepatomegaly or ascites.
Choice C rationale
Tremors are not typically associated with heart failure. They could be a sign of other neurological conditions, side effects of certain medications, or anxiety.
Choice D rationale
Bradycardia, or a slower than normal heart rate, is not typically a symptom of heart failure. In fact, tachycardia, or a faster than normal heart rate, is more commonly seen in heart failure as the heart tries to compensate for its reduced ability to pump blood.
Correct Answer is C
Explanation
Choice A rationale
Prolonged headache is not typically identified as a common trigger for seizures. While headaches can be associated with certain types of seizures, they are not generally considered a trigger for seizure activity.
Choice B rationale
Decreased temperature, or hypothermia, is not typically identified as a common trigger for seizures. In fact, fever or increased body temperature is more commonly associated with triggering seizures, particularly in children.
Choice C rationale
Lack of sleep is a well-recognized trigger for seizures. Sleep deprivation can lead to increased seizure frequency in individuals with epilepsy. Ensuring adequate sleep is an important part of managing seizure disorders.
Choice D rationale
Exposure to second-hand smoke is not typically identified as a common trigger for seizures. While it is generally harmful to health, it is not specifically associated with an increased risk of seizures.
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