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.

Answer and Explanation

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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Correct Answer is ["31"]

Explanation

Step 1: Determine the total volume to be infused.

Total volume = 250 mL

Step 2: Determine the total time for infusion in minutes.

Total time = 2 hours
Convert hours to minutes: 2 hours × 60 minutes/hour = 120 minutes
Result: 120 minutes

Step 3: Determine the drop factor.

Drop factor = 15 gtts/mL

Step 4: Calculate the flow rate in drops per minute.

Flow rate (gtts/min) = (Total volume in mL × Drop factor) ÷ Total time in minutes
Flow rate (gtts/min) = (250 mL × 15 gtts/mL) ÷ 120 minutes
Result: (250 × 15) = 3750
Result: 3750 ÷ 120 = 31.25

Step 5: Round the result to the nearest whole number.

Rounded result: 31

Final Answer: The nurse should adjust the flow rate to deliver 31 drops per minute.

A. Muffled heart sounds. B. Sudden lethargy. C. Flattened neck veins. D. Bradycardia.

Correct Answer is A

Explanation

Choice A reason:

The statement “Muffled heart sounds” is a classic sign of cardiac tamponade. This condition occurs when fluid accumulates in the pericardium (the sac around the heart), compressing the heart and preventing it from functioning properly. Muffled heart sounds are due to the fluid dampening the sound of the heartbeats. This is part of Beck’s triad, which also includes hypotension and jugular venous distension.

Choice B reason:

The statement “Sudden lethargy” is not a specific indicator of cardiac tamponade. While lethargy can occur due to decreased cardiac output and poor perfusion, it is not a definitive sign of cardiac tamponade. Lethargy can be caused by various conditions and is not specific enough to support the suspicion of cardiac tamponade.

Choice C reason:

The statement “Flattened neck veins” is incorrect. In cardiac tamponade, one would expect to see distended (bulging) neck veins due to increased central venous pressure. Flattened neck veins are not consistent with the hemodynamic changes seen in cardiac tamponade.

Choice D reason:

The statement “Bradycardia” is not typically associated with cardiac tamponade. Instead, tachycardia (an increased heart rate) is more commonly seen as the body attempts to compensate for decreased cardiac output. Bradycardia can occur in severe cases or as a pre-terminal event, but it is not a primary indicator of cardiac tamponade.

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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)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["31"]

Explanation

A nurse is caring for a client in a critical care unit who suffered a knife wound to the chest. The nurse suspects the client is developing cardiac tamponade. Which of the following assessment findings should the nurse identify as supporting this suspicion?

Correct Answer is A

Explanation

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