A nurse is performing a developmental assessment on a 4-year-old client. What assessment finding would warrant further investigation?
The client has urinary and bowel continence.
The client is unable to tie their shoes.
The client introduces their "friend" who is not visible to the nurse.
The client speaks in 2-3 word sentences.
The Correct Answer is D
A. Urinary and bowel continence is expected by age 4, so this does not warrant further investigation.
B. Tying shoes is a skill typically developed later, around 5-6 years of age, so not being able to do so at age 4 is not concerning.
C. Having an imaginary friend is common in children around this age and is not a cause for concern.
D. Speaking in 2-3 word sentences is typical for a younger child, around 2 years of age. By age 4, a child should be able to speak in more complex sentences, so this finding warrants further investigation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Neurologic function is not typically affected by nephrotic syndrome, so improvement in this area is not an indicator of recovery.
B. Weight gain might indicate fluid retention rather than recovery in nephrotic syndrome.
C. The absence of protein in the urine indicates that the kidneys are functioning properly and that the syndrome is resolving. Proteinuria is a hallmark of nephrotic syndrome, so its resolution is a key sign of recovery.
D. A negative gram stain is more relevant to infections, not nephrotic syndrome.
Correct Answer is B
Explanation
. While pain management is important, the primary treatment for pyloric stenosis is surgical correction, not just analgesic medication.
B. Preparation for surgical correction, specifically a pyloromyotomy, is the standard treatment for pyloric stenosis to relieve the obstruction.
C. A barium enema is not used in the diagnosis or treatment of pyloric stenosis; it is typically used to diagnose other gastrointestinal conditions.
D. Thickened feedings with rice cereal are not indicated for pyloric stenosis and would not resolve the obstruction.
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