A nurse is assessing the developmental milestones of a 2-year-old child during a well-child visit.
The parents state they have concerns because the child does not speak much and is having difficulty learning to walk.
Which of the following statements should the nurse make?
"Don't worry, they are fine. We see this frequently and it is usually nothing to be concerned about.”.
"I understand you have some concerns about their development. While each child develops at their own pace, we can discuss your concerns with the primary care provider.”.
"Your child is only 2 years old. My child barely spoke until they were 3 years old, and they are just fine now.”.
"It is probably just a phase; they will grow out of it. If you still have these concerns in 6 months, we can assess it further.”.
The Correct Answer is B
Choice A rationale
This response is non-therapeutic because it uses false reassurance and minimizes the parents' valid concerns. In pediatric nursing, it is critical to acknowledge that developmental delays in speech or motor skills at age 2 can be early indicators of underlying issues. Dismissing these concerns without a formal assessment ignores the importance of early intervention. Scientific practice requires a thorough evaluation of milestones against standardized growth charts rather than offering anecdotal or empty comfort.
Choice B rationale
This statement is therapeutic as it validates the parents' feelings while maintaining professional boundaries and acknowledging developmental variability. A 2-year-old child should typically be walking independently and using simple phrases. By suggesting a discussion with the primary care provider, the nurse facilitates a professional assessment. This approach ensures that any potential neurological or musculoskeletal delays are investigated according to evidence-based practice guidelines, ensuring the child receives necessary support or referrals if required.
Choice C rationale
Using personal examples is unprofessional and constitutes a barrier to effective communication. The developmental progress of the nurse's own child is scientifically irrelevant to the clinical assessment of the patient. Each child must be measured against objective milestones; for example, most children use at least 50 words by age 2. Relying on personal stories can lead to a delay in diagnosing actual developmental disorders, which contradicts the nurse's duty to provide objective, patient-centered care.
Choice D rationale
Advising the parents to wait six months is clinically inappropriate and potentially harmful. Early childhood is a critical window for neuroplasticity, and delays in walking or talking at 24 months warrant immediate attention rather than a "watch and wait" approach. Postponing an assessment could lead to a missed opportunity for early intervention services, such as physical or speech therapy. Scientific evidence suggests that the earlier a developmental delay is addressed, the better the long-term functional outcomes.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D","E"]
Explanation
Choice A rationale
Influenza acquired from a coworker is considered a community-acquired infection or an occupational exposure rather than a healthcare-associated infection (HAI). HAIs specifically refer to infections that patients acquire while receiving treatment for other conditions within a healthcare setting. Since this infection originated from a peer interaction rather than as a direct result of clinical procedures or the healthcare environment during patient care, it does not meet the criteria for an HAI.
Choice B rationale
A bladder infection in a client with an indwelling urinary catheter is a classic example of a healthcare-associated infection, specifically a Catheter-Associated Urinary Tract Infection (CAUTI). These occur when bacteria enter the urinary tract via the catheter during insertion or maintenance. HAIs like CAUTIs are significant indicators of quality of care, as they are often preventable through strict adherence to sterile techniques and timely removal of the device when no longer needed.
Choice C rationale
An infection at a central-line insertion site is a healthcare-associated infection known as a Central Line-Associated Bloodstream Infection (CLABSI). These infections occur when pathogens enter the bloodstream through the central venous catheter. They are often related to the insertion process or the subsequent handling of the line. Because the infection is a direct consequence of a medical device placed during the client's stay in the facility, it is categorized as an HAI.
Choice D rationale
Pneumonia that develops after a client has been on a ventilator is known as Ventilator-Associated Pneumonia (VAP), which is a type of healthcare-associated infection. The ventilator provides a pathway for pathogens to bypass normal respiratory defenses and enter the lungs. Since this condition arises specifically due to the mechanical ventilation required during the client's medical treatment in the hospital, it is classified as an HAI that requires focused prevention strategies.
Choice E rationale
A surgical site infection (SSI) is an infection that occurs after surgery in the part of the body where the surgery took place. SSIs are healthcare-associated infections because they result from the surgical procedure performed within the healthcare facility. These infections can range from superficial involving the skin to deep infections involving organs or implanted materials. They are a major focus of HAI surveillance and represent a complication of the healthcare delivery process.
Correct Answer is D
Explanation
Choice D rationale
The planning phase of the nursing process involves the development of a care plan based on the identified nursing diagnoses. A central part of this phase is formulating measurable, client-centered goals and expected outcomes. These goals provide a roadmap for nursing interventions and serve as the criteria for evaluating the effectiveness of the care provided. By setting these targets, the nurse ensures that the entire healthcare team is working toward a specific, positive outcome for the patient.
Choice A rationale
Evaluation is the final step of the nursing process where the nurse determines if the client has met the goals that were previously established. During this phase, the nurse compares the client's actual health status with the desired outcomes. While evaluation is closely linked to goals, it is the process of checking progress rather than the act of formulating the goals themselves. Formulating the targets for success must happen before they can be evaluated in practice.
Choice B rationale
Implementation is the action phase of the nursing process where the nurse carries out the planned nursing interventions. This includes performing clinical tasks, delegating care, and documenting the actions taken. While these actions are designed to help the client achieve their goals, the actual creation and wording of the goals occur during the planning stage. Implementation is about doing the work that was organized during the planning phase to move the client toward the desired health status.
Choice C rationale
Assessment is the first step of the nursing process, involving the systematic collection of subjective and objective data about the client's health. This data is used to identify the client's needs and formulate nursing diagnoses. While assessment provides the information necessary to set appropriate goals, the specific task of defining what a positive outcome looks like is reserved for the planning phase. Assessment is about gathering facts, whereas planning is about deciding on the future direction of care.
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