A nurse is performing a developmental assessment on a 4-year-old client. What assessment finding would warrant further investigation?
The client has urinary and bowel continence.
The client is unable to tie their shoes.
The client introduces their "friend" who is not visible to the nurse.
The client speaks in 2-3 word sentences.
The Correct Answer is D
Rationale:
A. Urinary and bowel continence is expected by age 4, so this does not warrant further investigation.
B. Tying shoes is a skill typically developed later, around 5-6 years of age, so not being able to do so at age 4 is not concerning.
C. Having an imaginary friend is common in children around this age and is not a cause for concern.
D. Speaking in 2-3 word sentences is typical for a younger child, around 2 years of age. By age 4, a child should be able to speak in more complex sentences, so this finding warrants further investigation.
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Correct Answer is B
Explanation
Rationale:
A. Granola often contains gluten, so this meal would not be suitable for someone with celiac disease.
B. Cheese, banana slices, rice cakes, and whole milk are gluten-free and appropriate for a child with celiac disease.
C. Rye toast contains gluten, which is contraindicated for someone with celiac disease.
D. Flour tortillas generally contain gluten, so this meal is not appropriate for someone with celiac disease.
Correct Answer is A
Explanation
Rationale:
A. Profound cyanosis is a key sign of tricuspid atresia, a congenital heart defect where the tricuspid valve is absent, leading to poor oxygenation of the blood.
B. Periorbital edema is not typically associated with tricuspid atresia; it might be seen in other conditions like nephrotic syndrome.
C. Absent femoral pulses suggest coarctation of the aorta rather than tricuspid atresia.
D. Decreased blood pressure in the lower extremities is also more indicative of coarctation of the aorta, not tricuspid atresia.