a nurse working in a pediatric clinic and observes the following situations which of the following may indicate a delayed child to the nurse a nurse working in a pediatric clinic and observes the following situations which of the following may indicate a delayed child to the nurse
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Nursing Elites

NCLEX NCLEX-PN

NCLEX-PN Quizlet 2023

1. A nurse working in a pediatric clinic observes the following situations. Which of the following may indicate a delayed child to the nurse?

Correct answer: A 12-month-old that does not 'cruise'.

Rationale: The correct answer is 'A 12-month-old that does not 'cruise''. At 12 months, a child should at least be 'cruising' (holding on to objects to walk), which is considered pre-walking. The other choices describe age-appropriate developmental milestones: sitting upright unsupported by 8 months, rolling prone to supine by 6 months, and rolling supine to prone by 3 months. Not 'cruising' at 12 months may indicate a delay in motor skills development.

2. A nurse is assisting with data collection regarding the motor development of a 24-month-old child. Which activities would the nurse expect the mother to report that the child can perform?

Correct answer: Align two or more blocks

Rationale: By 24 months of age, a child can perform various activities. While the child may be able to put on simple items of clothing, distinguishing front from back might still be a challenge. They may also be able to zip large zippers, put on shoes, wash and dry their hands, align two or more blocks, and turn book pages one at a time. However, the fine motor skill required to tie shoes is usually not developed at this age. Full independence in dressing, using the bathroom, and eating typically occurs around 4 to 5 years of age. Therefore, the correct expectation for a 24-month-old child would be aligning two or more blocks. Choices A, B, and C are incorrect as they represent skills that are usually achieved at a later age.

3. Which intervention should the nurse stop the nursing assistant from performing?

Correct answer: Placing the traction weights on the bed to transfer the client to X-ray

Rationale: Placing traction weights on the bed to transfer the client to X-ray is an intervention that the nurse should stop the nursing assistant from performing. Traction should never be relieved without a doctor's order as it can result in muscle spasm and tissue damage. The other choices are appropriate nursing interventions and should not be stopped. Emptying the Jackson-Pratt drainage, performing passive range of motion, and collecting the first urine void for a 24-hour urine test are all within the scope of practice and do not pose immediate risks to the client's well-being.

4. When assessing a client's mobility status, the physical examination should start with:

Correct answer: examining their gait.

Rationale: When assessing a client's mobility status, it is crucial to start by examining their gait. Gait assessment is usually conducted as the client walks into the room. Normal gait is described as smooth, flowing, and rhythmic without the need for assistive devices. Choices B, C, and D are incorrect as they do not represent the standard practice of beginning the assessment of mobility status with gait examination.

5. Following an automobile accident that caused a head injury to an adult client, the nurse observes that the client sleeps for long periods of time. The nurse determines that the client has experienced injury to the:

Correct answer: hypothalamus.

Rationale: The hypothalamus is responsible for regulating sleep patterns among other functions. Injury to the hypothalamus can disrupt the sleep-wake cycle, leading to excessive sleepiness or changes in sleep patterns. Choices B, C, and D are incorrect as they do not primarily control sleep regulation. The thalamus is involved in relaying sensory information, the cortex is responsible for higher brain functions, and the medulla controls vital functions such as heartbeat and breathing.

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