The nurse is performing a physical assessment of a 3-year-old girl. What finding would be a concern for the nurse?
The toddler's anterior fontanel is not fully closed.
The toddler gained 3 in in height since last year.
The toddler gained 4 lb in weight since last year.
The circumference of the child's head increased 1 in since last year.
The Correct Answer is A
A. The toddler's anterior fontanel is not fully closeD. The closure of the anterior fontanel typically occurs by around 18 months of age. If the fontanel is still open at 3 years old, it may indicate a delay in normal development and could be a cause for concern. The nurse should further assess this finding and consider follow-up with the healthcare provider.
B. The toddler gained 3 in in height since last year: Growth in height is expected during early childhood, and a gain of 3 inches over a year is within the normal range for a 3-year-old.
C. The toddler gained 4 lb in weight since last year: Weight gain is also expected during early childhood, and a gain of 4 pounds over a year is within the normal range for a 3-year-old.
D. The circumference of the child's head increased 1 in since last year: Head circumference typically increases during early childhood as the brain grows, and a 1-inch increase over a year is within the normal range for a 3-year-old.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Obtain a detailed history.
Obtaining a detailed history is essential to understand the circumstances surrounding the bruises, including how they occurred, where they are located, and whether there is a plausible
explanation for them. This information helps determine whether the bruises are due to accidental injury or potential abuse.
B. Report the suspected abuse to the authorities.
While reporting suspected abuse may ultimately be necessary if there are concerns about the origin of the bruises, obtaining a detailed history is the initial step to gather information and assess the situation before making a report.
C. Ask a psychiatrist to talk with the parents.
Involving a psychiatrist may be appropriate in cases where there are concerns about the child's mental health or the family dynamics, but it may not address the immediate concern of the bruises without first obtaining a detailed history.
D. Separate the child from the parents.
Separating the child from the parents should not be the first action taken without sufficient evidence or reason to believe that the child is in imminent danger. Gathering information through a detailed history is essential before considering such a drastic measure.
Correct Answer is C
Explanation
A. Poisoning: While poisoning can be a significant concern among adolescents, it is not the
leading cause of death in this age group. Poisoning deaths may occur due to accidental ingestion of toxic substances or intentional overdose, but it is not as common as other causes of death
among adolescents.
B. Drowning: Drowning is a concern, especially during recreational activities such as swimming, but it is not the leading cause of death among adolescents. Proper water safety practices and supervision can help prevent drowning incidents.
C. Unintentional injuries: Unintentional injuries, including motor vehicle accidents, falls, and other accidents, are the leading cause of death among adolescents. Risk-taking behaviors, lack of experience, and peer influence contribute to the high rate of unintentional injuries in this age group.
D. Diseases: While diseases such as cancer, heart disease, and respiratory disorders can affect adolescents, they are not the leading cause of death in this age group. Unintentional injuries,
including those resulting from accidents and trauma, are more common causes of death among adolescents.
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