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
A. Mild illnesses like nasopharyngitis (a common cold) do not typically contraindicate vaccination, so there is no need to delay immunization.
B. It is essential to evaluate for allergies to vaccine components, such as gelatin or neomycin, which could contraindicate the administration of the varicella vaccine.
C. The first dose of the varicella vaccine is recommended at 12-15 months of age, not at 4 years of age, so it is appropriate to administer it during this well-check.
D. The varicella vaccine is administered subcutaneously, not intramuscularly, so this is not the correct route for administration.
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