The nurse is interviewing a 3-year-old girl who tells the nurse: “Want go potty.” The parents tell the nurse that their daughter often speaks in this type of broken speech. What would be the nurse’s appropriate response to this concern?
This is a condition known as stuttering and it is a normal pattern of speech development in the toddler
This is a condition known as echolalia and can be corrected if you work with your daughter on language skills
This is considered a developmental delay in the 3-year-old and we should consult a speech therapist
This is a normal, common speech pattern in the 3-year-old and is called telegraphic speech
The Correct Answer is D
Choice A reason: Stuttering involves repetition or prolongation of sounds, not omitting words for brevity. Telegraphic speech, where toddlers use short phrases like “want go potty,” is normal at age 3, reflecting developmental language simplification, not a fluency disorder like stuttering, making this an incorrect response.
Choice B reason: Echolalia is the repetition of others’ words, often seen in autism, not the use of short, functional phrases. The described speech, “want go potty,” is telegraphic, a normal toddler pattern, not echolalia requiring correction, making this an inaccurate response for the observed speech pattern.
Choice C reason: Telegraphic speech is normal in 3-year-olds, not a developmental delay. Consulting a speech therapist is unnecessary unless other language milestones are delayed. The described speech pattern, using key words without connectors, is typical for this age, making this response incorrect and overly interventionist.
Choice D reason: Telegraphic speech, common in 3-year-olds, involves short phrases with essential words (e.g., “want go potty”), omitting articles or connectors. This is a normal developmental stage as toddlers simplify language to communicate effectively, aligning with the described speech pattern, making this the correct response.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["230"]
Explanation
Step 1: Convert 1/2 cup of juice to milliliters.
1 cup = 240 mL
1/2 cup = 240 mL ÷ 2 = 120 mL
Result at step 1 = 120 mL
Step 2: Convert 3 ounces of gelatin to milliliters.
1 ounce = 30 mL
3 ounces × 30 mL = 90 mL
Result at step 2 = 90 mL
Step 3: Convert 1 ounce of ice pop to milliliters.
1 ounce = 30 mL
Result at step 3 = 30 mL
Step 4: Note the ginger ale intake.
The child consumed 20 mL of ginger ale, which is already in milliliters.
Result at step 4 = 20 mL
Step 5: Sum the fluid intake from all items.
120 mL + 90 mL + 30 mL + 20 mL = 260 mL
Result at step 5 = 260 mL
Final answer 230 mL
Correct Answer is C
Explanation
Choice A reason: Obtaining a detailed history is important to identify the ingested substance, but it is not the first priority in a lethargic child. Lethargy may indicate compromised airway, breathing, or circulation, which are life-threatening. Addressing immediate physiological stability takes precedence over history collection in an emergency setting.
Choice B reason: Obtaining vital signs and assessing perfusion is critical in evaluating a child with potential poisoning, but it is secondary to ensuring airway and breathing stability. Lethargy may signal respiratory depression or hypoxia, which require immediate assessment to prevent further deterioration before vital signs are fully evaluated.
Choice C reason: Assessing the child’s airway and breathing is the first priority in a lethargic child with suspected ingestion. Lethargy may indicate central nervous system depression or hypoxia, which can compromise airway patency and respiratory function. Immediate assessment ensures life-threatening conditions are addressed first, following the ABCs (airway, breathing, circulation) of emergency care.
Choice D reason: Administering activated charcoal may be appropriate to prevent absorption of certain toxins, but it is not the first priority. Without ensuring airway and breathing stability, charcoal administration could be unsafe, especially if the child is lethargic and at risk for aspiration, making this a secondary intervention.
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