A nurse is caring for a 3-year-old patient. Which behavior is developmentally appropriate for this patient?

The patient ties his shoelaces.

The patient gives his first and last name.

The patient can tell time.

The patient draws a stick figure with six parts.

Answer and Explanation

The Correct Answer is D

Choice A rationale:

The patient ties his shoelaces. This choice is incorrect as most 3-year-olds lack the fine motor skills required to tie shoelaces independently.

Choice B rationale:

The patient gives his first and last name. This choice is also incorrect, as most 3-year-olds might not have developed language skills to provide their full name accurately.

Choice C rationale:

The patient can tell time. This choice is unrealistic for a 3-year-old, as telling time involves cognitive and conceptual abilities that are not yet developed at this age.

Choice D rationale:

The patient draws a stick figure with six parts. This choice is correct. Around age 3, children usually start drawing simple figures with a head, arms, legs, and possibly facial features, totaling around six parts. This reflects appropriate developmental milestones for a child of this age.

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Correct Answer is D

Explanation

Choice A rationale:

Monitoring the patient's breathing pattern at 15-minute intervals is crucial in an unconscious patient who may have ingested alcohol or drugs, as it helps assess their respiratory status. This intervention ensures early detection of any respiratory distress and guides necessary interventions.

Choice B rationale:

Inserting an indwelling Foley catheter for straight drainage is appropriate for unconscious patients to monitor their urinary output and renal function. This helps prevent urinary retention and complications related to inadequate urine elimination.

Choice C rationale:

Administering IV D5/45 NS at 100 mL/hr is a suitable intervention to maintain the patient's fluid and electrolyte balance. It prevents dehydration and supports hemodynamic stability.

Choice D rationale:

The nurse should question the prescription of syrup of ipecac. Ipecac is no longer recommended for use in cases of poisoning due to its potential to cause adverse effects like aspiration, electrolyte imbalances, and delayed treatment. Activated charcoal or gastric lavage may be more appropriate in this situation.

A. "The improvement may indicate a misdiagnosis of insulin-dependent diabetes mellitus.". B. "The improvement is evidence of the creation of new insulin-producing cells in the pancreas.". C. "The improvement is a temporary response of the insulin-producing cells of the pancreas.". D. "The improvement is the beginning of a complete recovery for your child.".

Correct Answer is C

Explanation

Choice A rationale:

Misdiagnosis is unlikely since the glucose levels are improving, indicating a valid diagnosis.

Choice B rationale:

Insulin-producing cells don't regenerate in substantial amounts to normalize glucose levels within a month. This process takes longer.

Choice C rationale:

This choice correctly identifies the situation as a temporary improvement due to the remaining insulin-producing cells functioning better temporarily.

Choice D rationale:

Complete recovery is not likely in such a short time frame.

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A nurse is caring for a 3-year-old patient. Which behavior is developmentally appropriate for this patient?

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Naxlex Comprehensive Predictor Exams

A 14-year-old patient is brought unconscious to the emergency room. It is suspected that the patient has deliberately taken an overdose of acetaminophen with 1/2 pint of vodka. The healthcare provider prescribes several interventions. Which intervention should the nurse question?

Correct Answer is D

Explanation

A patient newly diagnosed with insulin-dependent diabetes mellitus comes to the clinic one month after diagnosis. The mother tells the nurse, "My child is getting better. The glucose levels are almost normal and my child requires less insulin.". What is the most appropriate response by the nurse?

Correct Answer is C

Explanation

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