During a 2-year-old well-child visit, a toddler's parent tells the nurse that this son, who is the youngest of five, rarely talks spontaneously. Which intervention should the nurse implement?

Suggest that the parent read aloud to the child at bedtime.

Discuss with the parent the need for a hearing screening.

Recommend that the parent enroll the child in preschool.

Encourage parent to tell the child to ask for what he wants.

Answer and Explanation

The Correct Answer is B

A. Suggest that the parent read aloud to the child at bedtime. Reading aloud to the child is a beneficial practice that can enhance language development, vocabulary, and communication skills. It provides the child with exposure to language in a meaningful context and can stimulate spontaneous speech.

B. Discuss with the parent the need for a hearing screening. A hearing screening is a prudent intervention as hearing issues can significantly impact speech development. Ensuring the child has normal hearing is a critical first step in addressing delayed speech. Once hearing issues are ruled out, reading aloud and other strategies can be more effectively implemented.

C. Recommend that the parent enroll the child in preschool. Enrolling the child in preschool can provide a language-rich environment and opportunities for social interaction, which can stimulate speech and language development. However, this may not be the first step without ruling out other issues like hearing problems.

D. Encourage the parent to tell the child to ask for what he wants. Encouraging the child to use words to express needs is helpful for language development. It promotes verbal communication and helps the child learn to articulate desires and needs. This strategy, combined with other interventions, can be effective.

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Correct Answer is D

Explanation

A. Advise the PN that waist circumference measurements are valuable to assess fluid retention but not obesity. Waist circumference is actually a valuable measure for assessing abdominal obesity, which is an important factor in health, independent of BMI. It helps screen for health risks related to overweight and obesity, such as heart disease and type 2 diabetes. Therefore, this option is incorrect.

B. Instruct the PN to measure the client’s waist circumference every 8 hours to assess for changes. Measuring waist circumference does not require frequent assessments like every 8 hours. It’s a simple and inexpensive measurement that provides valuable information about abdominal fat distribution. However, such frequent measurements are unnecessary and impractical for assessing obesity-related risks.

C. Tell the PN that this assessment technique should be performed by the nurse. Waist circumference measurements can be performed by practical nurses (PNs) and other healthcare providers. It’s a straightforward technique that doesn’t require specialized training. Therefore, this option is incorrect.

D. Review the measurement obtained by the PN and compare with ideal measurements for this client. This is the most appropriate action. The nurse should review the PNs measurement of the client’s waist circumference and compare it to established guidelines. Generally, a waist circumference greater than 35 inches for women or greater than 40 inches for men indicates increased risk of obesity-related health problems.

A. Demonstrates startle reflex. B. Has doubled birth weight. C. Turns head to locate sound. D. Plays "peek a boo."

Correct Answer is A

Explanation

A. Demonstrates startle reflex: The startle reflex (Moro reflex) typically disappears around 3-4 months of age. If a 6-month-old still demonstrates this reflex, it may indicate a developmental delay or neurological issue, requiring further evaluation.

B. Has doubled birth weight: Doubling of birth weight by 6 months is a normal developmental milestone. This response does not require further evaluation as it indicates appropriate growth.

C. Turns head to locate sound: Turning the head to locate sounds is expected at this age and demonstrates normal auditory and neurological development. This response does not require further evaluation.

D. Plays "peek a boo": Playing "peek a boo" is a typical social interaction for a 6-month-old and indicates normal social and cognitive development. This response does not require further evaluation.

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During a 2-year-old well-child visit, a toddler's parent tells the nurse that this son, who is the youngest of five, rarely talks spontaneously. Which intervention should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The charge nurse observes a practical nurse (PN) measuring the waist circumference of a client who has expressed a concern about health problems related to obesity. Which action should the nurse implement?

Correct Answer is D

Explanation

The nurse is assessing a 6-month-old infant. Which response requires further evaluation by the nurse?

Correct Answer is A

Explanation

Which assessment finding of an older adult client should the nurse associate with normal aging?

During a 2-year-old well-child visit, a toddler's parent tells the nurse that this son, who is the youngest of five, rarely talks spontaneously. Which intervention should the nurse implement?

A client is complaining of severe pain after being medicated one hour ago with hydrocodone with acetaminophen one tablet orally. Which intervention should the nurse implement next?

While counting the respirations of an adult client who is bedfast, the nurse observes that the client uses the sternocleidomastoid, trapezius, and abdominal muscles during respirations. Which action should the nurse take in response to this finding?

Which assessment technique should the nurse use to confirm the presence of papilledema in a client with a rapidly decreasing level of consciousness?

Which method is best for the nurse to use in determining early development of ascites?

A client reports episodes of syncope. Which assessment finding should the nurse anticipate?

During a health assessment, the client reports being treated for osteoarthritis. The nurse examines the client's hands and finds Heberden's nodes. Which finding should the nurse document in the client's medical record?