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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View Related questions
Correct Answer is D
Explanation
Rationale:
A. Dry mouth is expected postoperatively, especially if the child is not drinking adequate fluids, but it is not a sign of a complication.
B. Mild to moderate pain is expected after a tonsillectomy and should be managed with analgesics.
C. Dried flecks of blood in oral secretions can be normal immediately after surgery, but active bleeding would be concerning.
D. Frequent swallowing is a sign of possible postoperative bleeding, which is a serious complication that requires immediate evaluation and intervention.
Correct Answer is B
Explanation
Rationale:
A. Changing routines frequently might confuse the child rather than stimulate initiative.
B. Rewarding the child for showing initiative positively reinforces the behavior and encourages further development.
C. Allowing the child to make choices about playmates can foster independence but may not directly stimulate initiative.
D. Setting appropriate limits is important for a child's development, but not setting any limits can lead to behavioral issues rather than promoting initiative.