Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
Which of the following findings indicates to the nurse that the toddler has developmental delay?
A. Runs with a wide stance.
A toddler running with a wide stance is a common behavior at this age and does not necessarily indicate developmental delay. Toddlers often develop a wide base of support as they learn to balance and walk more confidently.
B. Falls when throwing a ball overhand.
Falling when throwing a ball overhand requires coordination and motor skills. By the age of 24 months, most toddlers can throw a ball with some degree of accuracy. Inability to do so may indicate a developmental delay in motor skills, making choice B the correct answer.
C. Refers to self by name.
Referring to oneself by name is a typical language development milestone around the age of 24 months. It demonstrates a basic understanding of self-identity and language, indicating appropriate developmental progress. This choice does not suggest a delay.
D. Goes up stairs with two feet on each step.
Going up stairs with two feet on each step is a gross motor skill that toddlers typically develop around 36 months of age. It requires balance and coordination. While it is advanced for a 24-month-old, it is not necessarily a sign of developmental delay. Therefore, this choice does not provide a clear indication of delay.
This question is an excerpt from Nurse Dive's nursing test bank - RN Comprehensive Predictor Proctored Exam. Take the full exam now
Full Explanation
Choice A rationale:
A toddler running with a wide stance is a common behavior at this age and does not necessarily indicate developmental delay. Toddlers often develop a wide base of support as they learn to balance and walk more confidently.
Choice B rationale:
Falling when throwing a ball overhand requires coordination and motor skills. By the age of 24 months, most toddlers can throw a ball with some degree of accuracy. Inability to do so may indicate a developmental delay in motor skills, making choice B the correct answer.
Choice C rationale:
Referring to oneself by name is a typical language development milestone around the age of 24 months. It demonstrates a basic understanding of self-identity and language, indicating appropriate developmental progress. This choice does not suggest a delay.
Choice D rationale:
Going up stairs with two feet on each step is a gross motor skill that toddlers typically develop around 36 months of age. It requires balance and coordination. While it is advanced for a 24-month-old, it is not necessarily a sign of developmental delay. Therefore, this choice does not provide a clear indication of delay.
Similar Questions
A nurse is providing discharge teaching to a client who has a new ostomy.
Which of the following instructions should the nurse include?
A. "Apply sterile gloves when changing your ostomy pouch.”
Applying sterile gloves when changing the ostomy pouch is essential for infection control. However, this is a standard practice and not specific to the client's condition. While important, it is not the priority instruction for a client with a new ostomy.
B. "Notify the provider if your stoma becomes pink and moist.”
Notifying the provider if the stoma becomes pink and moist is not crucial information for the client. A pink and moist stoma indicates good blood supply and healing
C. "Empty your ostomy pouch when it is half full.”
Emptying the ostomy pouch when it is half full is a general guideline to prevent leakage and maintain hygiene.
D. "Use a moisturizing soap to cleanse your stoma.”
Soaps with lotions or perfumes may interfere with the pouch seal or cause peristomal skin irritation. Rinse and dry well.
Full Explanation
Choice A rationale:
Applying sterile gloves when changing the ostomy pouch is essential for infection control. However, this is a standard practice and not specific to the client's condition. While important, it is not the priority instruction for a client with a new ostomy.
Choice B rationale:
Notifying the provider if the stoma becomes pink and moist is crucial information for the client. A pink and moist stoma indicates good blood supply and healing, while changes in color or moisture might indicate complications. This instruction is essential for the client's ongoing care and to prevent potential complications, making choice B the correct answer.
Choice C rationale:
Emptying the ostomy pouch when it is half full is a general guideline to prevent leakage and maintain hygiene.
Choice D rationale:
Soaps with lotions or perfumes may interfere with the pouch seal or cause peristomal skin irritation. Rinse and dry well.
A nurse is caring for a client who is taking disulfiram for alcohol use disorder and reports ingestion of alcohol.
For which of the following adverse effects should the nurse monitor?
A. Headache.
Headache is a common adverse effect of disulfiram when alcohol is consumed. It is part of the adverse reaction created by the drug to deter individuals from drinking. While headache is a known symptom, tinnitus is a more specific and distinctive adverse effect associated with disulfiram use.
B. Hypertension.
Hypertension is not a common adverse effect of disulfiram. Disulfiram does not directly impact blood pressure. Its primary action is to cause an adverse reaction when alcohol is consumed.
C. Tinnitus.
Tinnitus (ringing in the ears) is a known adverse effect of disulfiram when alcohol is ingested. Disulfiram inhibits the breakdown of acetaldehyde, leading to an accumulation of this toxic substance in the body. Tinnitus is one of the symptoms of this toxic reaction and is a significant concern in individuals taking disulfiram for alcohol use disorder.
D. Insomnia.
Insomnia is not a common adverse effect of disulfiram. Disulfiram works by creating an unpleasant reaction when alcohol is consumed, which deters individuals from drinking. This reaction does not typically manifest as insomnia.
Full Explanation
Choice A rationale:
Headache is a common adverse effect of disulfiram when alcohol is consumed. It is part of the adverse reaction created by the drug to deter individuals from drinking. While headache is a known symptom, tinnitus is a more specific and distinctive adverse effect associated with disulfiram use.
Choice B rationale:
Hypertension is not a common adverse effect of disulfiram. Disulfiram does not directly impact blood pressure. Its primary action is to cause an adverse reaction when alcohol is consumed.
Choice C rationale:
Tinnitus (ringing in the ears) is a known adverse effect of disulfiram when alcohol is ingested. Disulfiram inhibits the breakdown of acetaldehyde, leading to an accumulation of this toxic substance in the body. Tinnitus is one of the symptoms of this toxic reaction and is a significant concern in individuals taking disulfiram for alcohol use disorder.
Choice D rationale:
Insomnia is not a common adverse effect of disulfiram. Disulfiram works by creating an unpleasant reaction when alcohol is consumed, which deters individuals from drinking. This reaction does not typically manifest as insomnia.
A nurse is assessing a client who is taking digoxin to treat chronic heart failure.
Which of the following findings should indicate to the nurse that the client is developing digoxin toxicity?
A. Hearing loss.
Hearing loss is not a typical sign of digoxin toxicity. Digoxin toxicity primarily affects the visual system, leading to disturbances such as blurred or yellow-tinted vision. It can also cause various cardiac symptoms due to its effects on heart rhythm and contractility. Hearing loss is not a recognized symptom of digoxin toxicity.
B. Tachycardia.
Tachycardia (fast heart rate) can be a sign of digoxin toxicity. Digoxin can cause arrhythmias and alter heart rate, which may lead to tachycardia. While this is a possible symptom, it is not as specific as other manifestations, such as visual disturbances.
C. Blurred vision.
Blurred vision is a hallmark sign of digoxin toxicity. Digoxin can cause disturbances in color vision, such as seeing yellow or green halos around objects. Blurred vision is a significant indicator of digoxin toxicity and requires prompt medical attention.
D. Insomnia.
Insomnia is not a recognized symptom of digoxin toxicity. Digoxin toxicity primarily affects the cardiovascular and visual systems, leading to symptoms related to heart rhythm disturbances and vision changes. Insomnia is not a typical manifestation of digoxin toxicity.
Full Explanation
Choice A rationale:
Hearing loss is not a typical sign of digoxin toxicity. Digoxin toxicity primarily affects the visual system, leading to disturbances such as blurred or yellow-tinted vision. It can also cause various cardiac symptoms due to its effects on heart rhythm and contractility. Hearing loss is not a recognized symptom of digoxin toxicity.
Choice B rationale:
Tachycardia (fast heart rate) can be a sign of digoxin toxicity. Digoxin can cause arrhythmias and alter heart rate, which may lead to tachycardia. While this is a possible symptom, it is not as specific as other manifestations, such as visual disturbances.
Choice C rationale:
Blurred vision is a hallmark sign of digoxin toxicity. Digoxin can cause disturbances in color vision, such as seeing yellow or green halos around objects. Blurred vision is a significant indicator of digoxin toxicity and requires prompt medical attention.
Choice D rationale:
Insomnia is not a recognized symptom of digoxin toxicity. Digoxin toxicity primarily affects the cardiovascular and visual systems, leading to symptoms related to heart rhythm disturbances and vision changes. Insomnia is not a typical manifestation of digoxin toxicity.