A nurse is assessing a preschooler. Which of the following findings should indicate to the nurse a need for speech therapy? (Select all that apply)
The preschooler mispronounces words.
The preschooler speaks in three-word sentences.
The preschooler stutters when speaking.
The preschooler talks to himself when reading.
The preschooler speaks in a nasally tone.
Correct Answer : A,B,C,E
Choice A reason: The preschooler mispronounces words can be a sign of a speech sound disorder. While some mispronunciation is normal in early speech development, persistent difficulty with articulation may indicate a need for speech therapy to improve clarity and communication skills.
Choice B reason: The preschooler speaks in three-word sentences may indicate a delay in expressive language development. By preschool age, children typically use longer sentences and more complex language structures. Limited sentence length can suggest a need for further evaluation and intervention.
Choice C reason: The preschooler stutters when speaking can be a sign of a fluency disorder. Stuttering involves disruptions in the flow of speech, such as repetitions, prolongations, or blocks. Early intervention with speech therapy can help manage and reduce stuttering.
Choice D reason: The preschooler talks to himself when reading is generally not a concern. Self-talk can be a normal part of development and learning, as children often verbalize their thoughts and actions. It does not typically indicate a need for speech therapy.
Choice E reason: The preschooler speaks in a nasally tone can indicate a resonance disorder, which affects the quality of the voice. A nasally tone may result from structural issues or improper use of the vocal tract. Speech therapy can help address these issues and improve vocal quality.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Reinforce discharge teaching to clients
While reinforcing discharge teaching is important, it is not the immediate priority during a disaster situation with limited staff. The focus should be on addressing urgent and life-threatening needs first. Discharge teaching can be addressed once the immediate crisis is managed and resources are more available.
Choice B reason: Instruct the assistive personnel (AP) to focus on clients’ ADLs
Instructing assistive personnel to focus on clients’ activities of daily living (ADLs) is important for maintaining basic care, but it is not the highest priority in a disaster situation. The primary focus should be on preventing life-threatening emergencies and ensuring the safety of all clients.
Choice C reason: Stock additional unit supplies
Stocking additional unit supplies is a proactive measure, but it is not the immediate priority during a disaster with limited staff. Ensuring that clients are safe and that life-threatening emergencies are prevented takes precedence over restocking supplies.
Choice D reason: Focus on providing care that prevents life-threatening emergencies
Focusing on providing care that prevents life-threatening emergencies is the highest priority in a disaster situation. With limited staff, it is crucial to prioritize interventions that ensure the immediate safety and well-being of clients. This includes monitoring for and addressing any critical changes in clients’ conditions and providing necessary emergency care.
Correct Answer is A
Explanation
Choice A reason:
Decreasing the infusion rate is the appropriate action when a client experiences flushing and tachycardia while receiving IV vancomycin. These symptoms are indicative of “Red Man Syndrome,” a reaction that occurs when vancomycin is infused too quickly. Slowing the infusion rate can help alleviate these symptoms and prevent further complications.
Choice B reason:
Changing the IV infusion site is not necessary in this situation. The symptoms of flushing and tachycardia are related to the rate of vancomycin infusion, not the site of administration. Therefore, changing the site would not address the underlying issue.
Choice C reason:
Documenting that the client experienced an anaphylactic reaction to the medication is incorrect. Anaphylaxis is a severe, life-threatening allergic reaction that involves symptoms such as difficulty breathing, swelling of the face and throat, and a rapid drop in blood pressure. The symptoms described (flushing and tachycardia) are more consistent with Red Man Syndrome, not anaphylaxis.
Choice D reason:
Applying cold compresses to the neck area is not an effective intervention for managing the symptoms of Red Man Syndrome. The primary approach should be to slow the infusion rate of vancomycin. Cold compresses would not address the cause of the reaction.
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