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 B
Explanation
Choice A reason:
Administering iron dextran subcutaneously into the vastus lateralis is not the recommended route for this medication. It is typically administered intramuscularly.
Choice B reason:
Correct. The preferred method for administering iron dextran is intramuscularly using the Z-track method. This technique helps prevent leakage of the medication into the subcutaneous tissue.
Choice C reason:
Administering iron dextran subcutaneously into the deltoid is not the preferred route for this medication. It is typically administered intramuscularly.
Choice D reason:
While a 20-gauge needle may be appropriate for intramuscular injections, the Z-track method is the preferred technique for administering iron dextran intramuscularly. The gauge of the needle may vary depending on the specific circumstances and patient characteristics.
Correct Answer is D
Explanation
Choice A reason:
The color tool is not a pain assessment tool; it is used to assess oxygen saturation levels.
Choice B reason:
The FACES scale is commonly used for children who are 3 years of age and older, but it may not be suitable for an 18-month-old toddler who may have limited ability to express pain through facial expressions.
Choice C reason:
The visual analog scale is typically used for older children and adults. It may not be effective for assessing pain in an 18-month-old toddler.
Choice D reason:
The FLACC scale (Face, Legs, Activity, Cry, Consolability) is a validated pain assessment tool for young children, including toddlers. It evaluates specific behaviors related to pain, making it suitable for this age group.
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