A nurse is collecting data on an 18-month-old toddler at a wellness visit in the health care provider's office. During the appointment, the nurse asks the parent about developmental milestones. The parent states that the toddler has not said their first word yet. Which of the following actions by the nurse is accurate?

Complete a screening test for autism spectrum disorder (ASD).

Ask the parent about recent immunizations

Educate the parent that toddlers do not typically say their first word until 18-20 months of age.

Ask the parent if the toddler has a history of hospitalizations or surgeries.

Answer and Explanation

The Correct Answer is A

A. Complete a screening test for autism spectrum disorder (ASD). By 18 months, most toddlers have said their first word, and a lack of speech development can be an early sign of ASD or other developmental delays. The M-CHAT (Modified Checklist for Autism in Toddlers) is a common screening tool used at this age to assess for autism. Early identification allows for timely interventions.

B. Ask the parent about recent immunizations. While immunization history is important for overall health, there is no connection between vaccines and delayed speech development. This question does not directly address the developmental concern at hand.

C. Educate the parent that toddlers do not typically say their first word until 18-20 months of age. This is incorrect. Most toddlers say their first word around 12 months, and by 18 months, they typically have a vocabulary of several words. A lack of speech at this age warrants further assessment.

D. Ask the parent if the toddler has a history of hospitalizations or surgeries. While medical history is important, hospitalizations or surgeries are not the most common causes of delayed speech. Developmental screening is the most appropriate next step in evaluating speech delays.

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Correct Answer is C

Explanation

A. "Most vaccines require only one dose." Many vaccines require multiple doses or booster shots to ensure long-term immunity. For example, the influenza vaccine is given annually, and the pneumococcal vaccine may require boosters in high-risk children.

B. "Children who have underlying respiratory diseases should not receive vaccines." Children with underlying respiratory conditions (e.g., asthma, cystic fibrosis) are often at higher risk for complications from respiratory infections. Vaccination is especially important for these children to protect them from severe illness.

C. "Early immunization is key to the prevention of illnesses." Vaccinating children at the recommended ages helps build early immunity against preventable respiratory infections like influenza, pneumococcal disease, and pertussis. Early immunization reduces disease severity and complications.

D. "The rhinovirus can be prevented with a vaccine." The rhinovirus (which causes the common cold) does not have a vaccine because it has many different strains and mutates frequently. Vaccines are available for other respiratory illnesses, such as influenza, pneumonia, and pertussis.

A. "Kawasaki disease is an abnormal immune response that only affects the liver." B. "Kawasaki disease is an abnormal immune response that causes injury to the body's muscles." C. "Kawasaki disease is an abnormal immune response in which the body attacks the skin only." D. "Kawasaki disease is an abnormal immune system response that can weaken the coronary arteries."

Correct Answer is D

Explanation

A. "Kawasaki disease is an abnormal immune response that only affects the liver." This is incorrect. Kawasaki disease primarily affects the blood vessels, especially the coronary arteries, not just the liver. While liver inflammation can occur, it is not the main concern.

B. "Kawasaki disease is an abnormal immune response that causes injury to the body's muscles." This is incorrect. Kawasaki disease is a vasculitis (inflammation of blood vessels), not a muscle disorder. It mainly affects the heart and blood vessels, potentially leading to aneurysms and long-term cardiac complications.

C. "Kawasaki disease is an abnormal immune response in which the body attacks the skin only." This is incorrect. While skin changes (such as a rash, peeling skin, and red palms/soles) are common symptoms, the primary concern is inflammation of the coronary arteries, which can lead to serious heart complications.

D. "Kawasaki disease is an abnormal immune system response that can weaken the coronary arteries." This is correct. Kawasaki disease triggers inflammation in medium-sized arteries, particularly the coronary arteries, which supply blood to the heart. If untreated, this can lead to coronary artery aneurysms, myocardial infarction, or long-term heart disease.

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Naxlex Comprehensive Predictor Exams

A nurse is reinforcing education with the caregiver of a school-age child regarding immunizations to prevent respiratory infections. Which of the following information should the nurse include in the teaching?

Correct Answer is C

Explanation

A nurse is reinforcing education to a family with a child who has Kawasaki disease. Which of the following statements made by the caregiver indicates an understanding of the education provided?

Correct Answer is D

Explanation

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