Which statement by the mother of an 18-month-old would lead the nurse to believe that the child should be referred for further evaluation for developmental delay?

“My child has a vocabulary of approximately 20 words.”

“My child is still thumb sucking.”

“My child seems to be quite wary of strangers.”

“My child is able to stand but is not yet taking steps independently.”

Answer and Explanation

The Correct Answer is D

A. “My child has a vocabulary of approximately 20 words.”

This statement indicates language development, and an 18-month-old with a vocabulary of approximately 20 words is within the expected range. It's a positive indicator of language acquisition.

B. “My child is still thumb sucking.”

Thumb sucking is a common self-soothing behavior in infants and toddlers. While it's a normal behavior, it typically decreases with age. Thumb sucking alone may not necessarily be a cause for concern unless it persists significantly and interferes with other aspects of development.

C. “My child seems to be quite wary of strangers.”

Stranger anxiety is a normal developmental stage, and many children exhibit wariness or fear of unfamiliar people around the age of 18 months. It is considered a typical response and not necessarily indicative of developmental delay.

D. “My child is able to stand but is not yet taking steps independently.”

At 18 months, most children are expected to be walking independently. The inability to take independent steps might be a concern for gross motor skill development. While some variation is normal, a delay in achieving this milestone might prompt further evaluation to rule out any underlying developmental issues.

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Correct Answer is D

Explanation

A. Dark red, macular lesions, and very pruritic:

Varicella lesions are typically pink or red and start as macules (flat, red spots) that develop into papules (raised bumps) and then vesicles (fluid-filled blisters). Dark red macular lesions are not commonly associated with varicella.

B. Various stages of lesions present at the same time, appear in successive crops, and very pruritic:

The presence of various stages of lesions (papules, vesicles, crusts) simultaneously, occurring in successive crops, and being intensely itchy are typical features of varicella.

C. Yellowish, scaly patches present on the scalp:

Yellowish, scaly patches on the scalp are not typical of varicella. This description is more indicative of conditions like seborrheic dermatitis rather than the rash associated with chickenpox.

D. A pink maculopapular rash starts at the hairline and spreads down the body.

Varicella rash usually begins as pink or red spots that develop into small, itchy, fluid-filled blisters (vesicles). These vesicles can then progress to form crusts and scabs. The rash often starts on the face, scalp, or trunk and then spreads to other parts of the body, gradually covering the entire body.

Correct Answer is ["-195"]

Explanation

The water intake is half of 900 mL, which is 450 mL. The soft drink intake is 12 oz, which is equivalent to 355 mL. Therefore, the total fluid intake is 450 + 355 = 805 mL.

The urine output is the sum of the two voids, which is 600 + 350 = 950 mL. The drainage output is 50 mL. Therefore, the total fluid output is 950 + 50 = 1000 mL.

The net I/O is the difference between the fluid intake and output, which is 805 - 1000 = -195 mL. This means that the patient had a negative fluid balance of 195 mL during the night.

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Which statement by the mother of an 18-month-old would lead the nurse to believe that the child should be referred for further evaluation for developmental delay?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a school-age child with varicella. What should the nurse observe about the rash that is associated with this infection?

Correct Answer is D

Explanation

The client voided twice on your shift (600 mL, 350 mL) and drank half of his 900mL water pitcher plus a 12 oz soft drink during the night. There was 50 mL drainage from the hemovac during the night. Calculate the patient’s total I/O starting at 2300 and ending at 0700.

Correct Answer is ["-195"]

Explanation

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