A nurse is assessing a 4-year old preschooler. Which of the following findings should indicate to the nurse a need to refer the child for a possible developmental delay? (Select all that apply.)
The child occasionally reverses letters when writing.
The child is unable to follow simple two-step instructions.
The child occasionally stutters when excited or nervous.
The child has a vocabulary of fewer than 50 words
The child has difficulty sharing toys with peers
Correct Answer : B,D
A. Occasional letter reversal is common at this age and not a concern for developmental delay.
B. At 4 years old, a child should be able to follow simple two-step instructions. Difficulty doing so may indicate a developmental delay.
C. Occasional stuttering when excited or nervous is common and does not indicate a developmental delay.
D. A vocabulary of fewer than 50 words is concerning, as children at this age typically have a much larger vocabulary.
E. Difficulty sharing toys is developmentally normal for a 4-year-old and does not necessarily indicate a delay.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. A facial grimace is a common indicator of pain in infants and suggests discomfort, prompting further assessment.
B. Dry palms and feet are not specific indicators of pain and can be influenced by other factors such as dehydration or environmental conditions.
C. Wide-open eyes in an infant can occur for various reasons, including curiosity or surprise, and are not specifically indicative of pain.
D. Decreased muscle tone can indicate various conditions, but it is not a direct sign of pain and may require further evaluation.
Correct Answer is ["562.5"]
Explanation
To calculate the safe dosage for the patient, first convert the weight from pounds to kilograms, knowing that 1 kilogram equals 2.2 pounds. The child weighs 33 pounds, which is approximately 15 kilograms (33 / 2.2). According to the drug guide, the safe dosage is 75 mg/kg/day. For a child weighing 15 kg, the total safe daily dosage would be 1125 mg (15 kg * 75 mg/kg). Since the medication is to be divided into two doses per day (every 12 hours), the safe single dose would be half of the daily dosage, which is 562.5 mg.
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