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The nurse is teaching a group of parents about gross motor development of a 2-year old. According to the Denver Developmental Screening Test, which behavior is an example of the normal gross motor skill of a 2-year old?
- A. She can pull a toy behind her.
- B. She can copy a horizontal line.
- C. She can build a tower of eight blocks.
- D. She can broad jump.
Correct Answer: A
Rationale: Pulling a toy is a gross motor skill for a 2-year-old per the Denver Test. Copying a line and building a tower of eight blocks are fine motor skills. Broad jumping develops later.
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The nurse is caring for all of the following persons. Which one is most in need of restraints?
- A. An elderly man who is sitting in a chair
- B. A confused postoperative client who is picking at his nasal oxygen and nasogastric (NG) tube
- C. A confused woman who is in bed with the side rails up
- D. An adult who has just returned to the surgical floor from a postanesthesia care unit
Correct Answer: B
Rationale: The confused postoperative client risks dislodging critical tubes, necessitating restraints if non-restraint interventions fail. Others pose lower immediate risk.
The nurse is caring for a client with suspected acute rheumatic fever. Which of the following questions would be most important for the nurse to ask the client?
- A. Do you typically take all of your antibiotics when they are prescribed?
- B. Has anyone in your family had rheumatic fever?
- C. What has your temperature been over the past several days?
- D. Have you recently had a streptococcal throat infection?
Correct Answer: D
Rationale: Recent streptococcal infection (D) is the primary trigger for rheumatic fever, making it the most important question. Antibiotic compliance (A), family history (B), and fever (C) are relevant but less critical.
A client with chronic heart failure calls the clinic to report a weight gain of 3 lb (1.4 kg) over the last 2 days. Which information is most important for the nurse to ask this client?
- A. Diet recall for this current week
- B. Fluid intake for the past 2 days
- C. Medications and dosages taken over the past 2 days
- D. Presence of shortness of breath, coughing, or edema
Correct Answer: D
Rationale: Symptoms like shortness of breath, coughing, or edema (D) indicate fluid overload, a critical concern in heart failure. Diet (A), fluid intake (B), and medications (C) are relevant but secondary.
The nurse is assessing a child with suspected lead poisoning. Which of the following assessments is the nurse most likely to find?
- A. Complaints of numbness and tingling in feet
- B. Wheezing noted when lung sounds auscultated
- C. Excessive perspiration
- D. Difficulty sleeping
Correct Answer: A
Rationale: Complaints of numbness and tingling in feet. A child who has unusual neurologic signs or symptoms, neuropathy, footdrop, or anemia that cannot be attributed to other causes may be suffering from lead poisoning. This most often occurs when a child ingests or inhales paint chips from lead-based paint or dust from remodeling in older buildings.
A woman who had a tuberculosis test three days ago reports to the nurse to have the test read. Which finding, if present, indicates a positive result and a need for referral and follow-up?
- A. A red area 12 mm in diameter
- B. A raised area 10 mm in diameter
- C. Itching at the injection site
- D. A rash on the arm near the test site
Correct Answer: B
Rationale: A raised (indurated) area >10 mm indicates a positive TB skin test, requiring follow-up for potential latent or active TB.