When assessing an 18-month-old toddler, the nurse would expect the child to be able to:

Demonstrate independent dressing

Use a vocabulary of 300 words

Jump with both feet

Walk upstairs with one handheld

Answer and Explanation

The Correct Answer is C

A. Demonstrating independent dressing is usually not expected at 18 months. Toddlers are still developing fine motor skills and may need assistance with dressing.

B. Using a vocabulary of 300 words is advanced for an 18-month-old. At this age, most children have a more limited vocabulary, typically around 50 words or so.

C. Jump with both feet.

At 18 months of age, children are usually developing their motor skills, including gross motor skills like walking, running, and jumping. Jumping with both feet is an age-appropriate milestone for a toddler of this age.

D. Walking upstairs with one hand held is typically not expected at 18 months. This is a skill that develops later as toddlers gain more confidence in their mobility and coordination.

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Correct Answer is B

Explanation

A. Positive Western blot test: A positive Western blot test confirms HIV infection but doesn't provide information about the current immune status or progression of the disease.

B. CD4-T-cell count 180 cells/mm³.

The CD4-T-cell count is a crucial indicator of a person's immune system function, and it's a primary marker used to monitor the progression of HIV infection. A CD4 count of 180 cells/mm³ is significantly below the normal range (which is typically higher), indicating immunosuppression and an increased risk of opportunistic infections. Maintaining and improving immune function is a top priority in the care of clients with HIV.

C. Platelets 150,000/mm³: Platelet counts are important, but they are not the primary indicator for assessing the progression of HIV.

D. WBC 5.000/mm³: The white blood cell count (WBC) is important for assessing overall immune function, but it doesn't provide the same specific information about the immune system status as the CD4-T-cell count.

A. Place the infant in reverse Trendelenburg position B. Place the infant in the knee to chest position C. Take the infant's blood pressure in all extremities D. Notify the Physician

Correct Answer is C

Explanation

Option A (Place the infant in reverse Trendelenburg position) and option B (Place the infant in the knee to chest position) are not the immediate actions to address this situation. While these positions might be used in specific situations, assessing blood pressure is more appropriate in this context to evaluate for potential vascular issues.

Option C. Take the infant's blood pressure in all extremities.

In an infant with weaker femoral pulses compared to the brachial and radial pulses, there might be a concern about coarctation of the aorta (a narrowing of the aorta), which can affect blood flow to the lower extremities. To confirm this and assess for potential issues, taking blood pressure measurements in all four extremities is crucial. This comparison can help identify pressure differentials between the upper and lower extremities, which is a hallmark sign of coarctation of the aorta.

Option D (Notify the Physician) is generally a good step, but taking the blood pressure in all extremities should be done first to provide comprehensive information for the physician when discussing the infant's condition.

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When assessing an 18-month-old toddler, the nurse would expect the child to be able to:

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has HIV. Which of the following laboratory values is the nurse's priority?

Correct Answer is B

Explanation

The nurse is performing an admission assessment on the neonate and finds femoral pulses to be weaker than the brachial and radial pulses. The next nursing action should be

Correct Answer is C

Explanation

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