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.
Free Nursing Test Bank
- Free Pharmacology Quiz 1
- Free Medical-Surgical Quiz 2
- Free Fundamentals Quiz 3
- Free Maternal-Newborn Quiz 4
- Free Anatomy and Physiology Quiz 5
- Free Obstetrics and Pediatrics Quiz 6
- Free Fluid and Electrolytes Quiz 7
- Free Community Health Quiz 8
- Free Promoting Health across the Lifespan Quiz 9
- Free Multidimensional Care Quiz 10
View Related questions
Correct Answer is B
Explanation
Rationale:
A. Fluid intake is usually restricted to prevent fluid overload, which can worsen edema and hypertension in acute glomerulonephritis.
B. Administering antibiotics may be necessary, especially if the condition is secondary to a streptococcal infection, which is a common cause of acute glomerulonephritis.
C. Rest is typically encouraged rather than frequent ambulation, as activity can exacerbate symptoms.
D. Daily weights, not weekly, are crucial for monitoring fluid balance in acute glomerulonephritis.
Correct Answer is C
Explanation
Rationale:
A. Assuming all Asians have the same culture is a generalization and may not accurately represent the specific cultural background of the family in question.
B. Hiring an interpreter may be helpful for language translation but may not provide insights into the nuances of the family's cultural beliefs and practices.
C. Directly engaging with the family and listening to their perspectives allows for a better understanding of their specific cultural beliefs and preferences.
D. While research can provide valuable information, direct communication with the family is essential for truly understanding their cultural needs and preferences.