A nurse is collecting data from an 18-month-old toddler. Which of the following findings should the nurse report to the provider?
Speaks four words
Builds a tower of three blocks
Has temper tantrums
Jumps in place with both feet
The Correct Answer is A
Choice A reason:
At 18 months, a toddler should typically be saying more than four words. This finding may
indicate a potential delay in speech development, and it should be reported to the provider for further evaluation.
Choice B reason:
Building a tower of three blocks is an appropriate developmental milestone for an 18-month-old and does not warrant reporting.
Choice C reason:
Temper tantrums are a normal behavior for toddlers, as they are still developing emotional regulation skills. This finding does not require reporting unless it is severe or causing harm to the child.
Choice D reason:
Jumping in place with both feet is an appropriate developmental milestone for an 18-month-old and does not warrant reporting.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:
Using a bleach-based solution to clean the bedside table is an appropriate measure to prevent the spread of Clostridium difficile bacteria, as bleach is effective in killing spores.
Choice B reason:
While hand sanitizer is useful for killing many types of bacteria and viruses, it may not be as effective against Clostridium difficile spores. Washing hands with soap and water is preferred.
Choice C reason:
Placing the toddler in a negative-airflow room is not necessary for managing Clostridium difficile diarrhea. Standard precautions and proper hygiene are sufficient.
Choice D reason:
Loperamide is not typically recommended for managing Clostridium difficile diarrhea, as it may worsen the condition by slowing down the bowel motility. The primary treatment is discontinuing the antibiotic that caused the infection and, in some cases, using specific antibiotics to target the C. difficile bacteria.
Correct Answer is A
Explanation
Choice A reason:
Ensuring the child's safety is the top priority. If the child is in immediate danger, steps must be taken to protect them.
Choice B reason:
While providing emotional support to the child is important, ensuring their physical safety takes precedence.
Choice C reason:
Documenting injuries is important for a comprehensive assessment and for legal purposes, but it should follow ensuring the child's immediate safety.
Choice D reason:
Notifying law enforcement may be necessary, but ensuring the child's immediate safety comes first.
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