A nurse is conducting developmental assessments on several children in the day-care setting. Which two children does the nurse identify as having developmental delays?

A 5-year-old who is unable to zip his own jacket.

A 2-year-old who cannot recite her phone number.

A 6-year-old who is unable to sit still for a short story.

A 2-year-old who is unable to cut with scissors.

An 18-month-old toddler who is unable to phrase sentences.

Answer and Explanation

The Correct Answer is C

Choice A reason: This choice is incorrect. It is not unusual for a 5-year-old to have difficulty with zippers.
Choice B reason: This choice is incorrect. Reciting a phone number is not expected of a 2-year-old.
Choice C reason: This is one of the correct choices. A 6-year-old should be able to sit still for a short story, and difficulty doing so may indicate a developmental delay.
Choice D reason: This choice is incorrect. A 2-year-old typically does not have the fine motor skills to cut with scissors.
Choice E reason: This is one of the correct choices. An 18-month-old should be starting to phrase simple sentences, and the inability to do so may indicate a developmental delay.

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Correct Answer is D

Explanation

Choice A reason: While peer group acceptance is important, it is not the primary concern in this situation.
Choice B reason: Developing a sense of industry is part of Erikson's stages of psychosocial development but is not the primary nursing concern here.
Choice C reason: Whether the child can manage their own insulin and finger sticks is important, but safety is the primary concern.
Choice D reason: This is the correct choice. Ensuring the child's safety is paramount, as the school needs to be aware of the child's condition in case of a diabetes-related emergency.

A. Give the client six ounces of non-diet carbonated soda and instruct the client to drink it entirely. B. Document the glucose reading in the electronic medical record as the only action needed. C. Collect a blood specimen by venipuncture to send to the laboratory for serum glucose analysis. D. Prepare the prescribed dose of rapid-acting insulin from the sliding scale instructions.

Correct Answer is A

Explanation

Choice A reason: This is the correct choice. A blood glucose level of 56 mg/dL indicates hypoglycemia, and the immediate priority is to raise the blood sugar level. Non-diet carbonated soda can provide a quick source of sugar.
Choice B reason: Documenting the reading is important but does not address the immediate need to correct the low blood sugar.
Choice C reason: While confirming the reading with a laboratory test is a good practice, it is not the first action to take when dealing with hypoglycemia.
Choice D reason: Administering insulin would be contraindicated as it would lower the blood sugar even further.

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A nurse is conducting developmental assessments on several children in the day-care setting. Which two children does the nurse identify as having developmental delays?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

What is the primary nursing concern for an 8-year-old child with Type 1 diabetes who asks his mother not to tell anyone at school that he has diabetes?

Correct Answer is D

Explanation

The nurse obtains a fingerstick blood glucose level using bedside lancet/glucose meter equipment from a client with a prescribed sliding scale insulin protocol. The meter indicates 56 mg/dL (3.12 mmol/L). At this time, which intervention should the nurse implement first?

Correct Answer is A

Explanation

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