Question

The nurse is preparing to screen a child for developmental delays. What is the most appropriate action by the nurse prior to assessing motor skills?

Answer 1

Correct Answers:

Observe the child playing and offer age-appropriate toys.

Rationale :

🔷Naturalistic observation yields the most valid picture of gross and fine motor skills because the child moves spontaneously without performance anxiety.

🔷Offering age-appropriate toys (blocks, balls, crayons) invites a range of developmentally expected movements that reveal coordination, tone, and grasp.

🔷This approach respects child-centered assessment principles and builds rapport, improving cooperation for any later structured checks.

🔷Observing play first allows the nurse to note symmetry, endurance, balance, and problem-solving, which are integral to developmental screening.

🔷It also helps the nurse tailor any subsequent standardized motor tests to the child’s comfort and demonstrated ability.

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Answer 2

Correct Answers:

Offer the family time and privacy to be with the child before beginning post-mortem care

Rationale :

🔶The immediate priority is family-centered, compassionate care—ensuring privacy and time supports healthy grief and bereavement.

🔶Allowing presence with the child honors cultural, spiritual, and parental needs, which aligns with pediatric palliative care standards.

🔶This step conveys respect and dignity for the child and validates the family’s intense emotional experience.

🔶When families are given unhurried time, they are more prepared for subsequent post-mortem procedures and decisions.

🔶Early emotional support reduces traumatic stress and promotes trust in the health-care team during a profoundly vulnerable moment.

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Answer 3

Correct Answers:

Measurement of height and weight.

Rationale :

💠The first step in evaluating pediatric weight status is obtaining accurate height and weight, which are the inputs for BMI percentile.

💠Without precise anthropometrics, any downstream assessments (e.g., BMI for age/sex) may be invalid or misleading.

💠Establishing a reliable baseline supports monitoring of trends and evaluation of interventions over time.

💠Accurate measurements allow comparison with CDC/WHO growth charts, identifying overweight/obesity by percentile categories.

💠This foundational data also informs nutrition, activity, and metabolic risk counseling tailored to the child.

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Answer 4

Correct Answers:

"l prefer spending time with my friends and sometimes feel misunderstood by my parents."

Rationale :

💎Prioritizing peer relationships and feeling misunderstood by parents are typical of adolescent psychosocial development.

💎This reflects Erikson’s stage of Identity vs. Role Confusion, where teens explore belonging and self-definition.

💎Increased reliance on peer validation is developmentally normal and supports autonomy formation.

💎Transient parent-teen friction often accompanies the shift toward independent thinking and values exploration.

💎Recognizing these patterns helps nurses guide communication strategies and promote healthy coping in families.

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Answer 5

Correct Answers:

Ask the family for the child's prayer schedule and plan medical treatments around these times to support the child's spiritual needs.

Rationale :

◈Integrating family-identified spiritual practices into care demonstrates cultural humility and family-centered care.

◈Aligning treatments with scheduled meditation/prayer reduces distress, improves cooperation, and respects Buddhist routines.

◈Collaboration affirms the child’s spiritual coping, an important protective factor during hospitalization.

◈When feasible, timing care around prayer windows supports holistic well-being without compromising safety.

◈Documenting and communicating the plan enhances team consistency and trust with the family.

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Answer 6

Correct Answers:

The parents include high-protein foods such as cheese and eggs in the child's diet.

Rationale :

❖ In phenylketonuria (PKU), high-protein foods are rich in phenylalanine, which the child cannot adequately metabolize.

❖Excess phenylalanine risks neurotoxicity, leading to cognitive impairment if intake is not restricted.

❖The diet must use low-phenylalanine medical formula and carefully controlled protein substitutes under dietitian guidance.

❖Caregivers must also avoid aspartame (contains phenylalanine) and practice label vigilance for hidden sources.

❖Ongoing growth monitoring ensures adequate calories and micronutrients while keeping phenylalanine in the target range.

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Answer 7

Correct Answers:

The parents include high-protein foods such as cheese and eggs in the child's diet.

Rationale :

❖ In phenylketonuria (PKU), high-protein foods are rich in phenylalanine, which the child cannot adequately metabolize.

❖Excess phenylalanine risks neurotoxicity, leading to cognitive impairment if intake is not restricted.

❖The diet must use low-phenylalanine medical formula and carefully controlled protein substitutes under dietitian guidance.

❖Caregivers must also avoid aspartame (contains phenylalanine) and practice label vigilance for hidden sources.

❖Ongoing growth monitoring ensures adequate calories and micronutrients while keeping phenylalanine in the target range.

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Answer 8

Correct Answers:

"Temper tantrums are common at this age as children learn to express their emotions and assert independence."

Rationale :

🔵At 3 years, tantrums are a developmentally expected behavior as children navigate autonomy and emotion regulation.

🔵Validating this normal pattern reduces parental anxiety and opens the door to coaching strategies.

🔵Effective approaches include consistent limits, predictable routines, and positive reinforcement for desired behaviors.

🔵Teaching calm responses and avoiding reinforcement of tantrums (e.g., giving in) fosters better self-control.

🔵Guidance on safety during tantrums and triggers can decrease frequency and intensity over time.

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Answer 9

Correct Answers:

Development of body odor

Rationale :

🟢Around 8–10 years, adrenarche activates apocrine glands, making body odor a common early change in girls.

🟢This precedes many secondary sexual characteristics and often signals the beginning of pubertal hormonal shifts.

🟢Anticipatory guidance about hygiene and deodorant use supports self-esteem and comfort.

🟢Recognizing this as age-appropriate prevents unnecessary concern about early puberty.

🟢Monitoring for additional signs helps track pubertal progression and identify any abnormal patterns.

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Answer 10

Correct Answers:

"Your child will need a low-phenylalanine diet for life and close monitoring."

Rationale :

⭐Phenylketonuria (PKU) is a lifelong metabolic disorder caused by a deficiency of the enzyme phenylalanine hydroxylase, leading to toxic accumulation of phenylalanine if not restricted.

⭐The most critical intervention is a strict low-phenylalanine diet for life, started in infancy, to prevent irreversible neurological damage, including intellectual disability, seizures, and developmental delays.

⭐Dietary therapy involves a special phenylalanine-free medical formula and carefully regulated amounts of natural protein under close metabolic and dietitian supervision.

⭐Regular blood monitoring is essential to maintain phenylalanine levels within the safe range, ensuring both growth and cognitive development are protected.

⭐Early education of parents about lifelong adherence prevents lapses that can still harm the developing brain, even beyond early childhood.

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QLexNursing

1 :
The nurse is preparing to screen a child for developmental delays. What is the most appropriate action by the nurse prior to assessing motor skills?

2 :
The nurse is preparing to provide post-mortem care for a 7-year-old child who has died after a prolonged illness. Which action should the nurse take first to support the family during this time?

3 :
The nurse assesses a 10-year-old child whose mother expresses concern about the child's weight. The child is overweight, and the mother is unsure about how to help the child. What is the first step the nurse should take to assess the child's weight status?

4 :
The nurse is assessing an adolescent client's development. Which statement by the adolescent indicates appropriate psychosocial development for their age group?

5 :
A 6-year-old child with a chronic illness practices Buddhism. The parents inform the nurse that their child observes specific meditation and prayer times daily for spiritual healing. How should the nurse best incorporate this practice into the child's care plan?

6 :
The nurse is evaluating the home care plan for a I-year-old diagnosed with phenylketonuria. Which action by the parents indicates a need for further teaching?

7 :
The nurse is evaluating the home care plan for a I-year-old diagnosed with phenylketonuria. Which action by the parents indicates a need for further teaching?

8 :
A parent expresses concern that their 3-year-old is still having frequent temper tantrums. Which of the following should the nurse emphasize when responding to the parent?

9 :
The nurse is teaching a group of parents about the developmental milestones in preadolescent children. Which of the following should the nurse emphasize as an important milestone for 9-year-old girls?

10 :
The nurse is educating the parents of a 2-week-old infant who has been diagnosed with phenylketonuria (PKU) after a positive metabolic screening. Which of the following is the most important dietary instruction to prevent long-term neurological damage?

QLexNursing

1 : The nurse is preparing to screen a child for developmental delays. What is the most appropriate action by the nurse prior to assessing motor skills?

2 : The nurse is preparing to provide post-mortem care for a 7-year-old child who has died after a prolonged illness. Which action should the nurse take first to support the family during this time?

3 : The nurse assesses a 10-year-old child whose mother expresses concern about the child's weight. The child is overweight, and the mother is unsure about how to help the child. What is the first step the nurse should take to assess the child's weight status?

4 : The nurse is assessing an adolescent client's development. Which statement by the adolescent indicates appropriate psychosocial development for their age group?

5 : A 6-year-old child with a chronic illness practices Buddhism. The parents inform the nurse that their child observes specific meditation and prayer times daily for spiritual healing. How should the nurse best incorporate this practice into the child's care plan?

6 : The nurse is evaluating the home care plan for a I-year-old diagnosed with phenylketonuria. Which action by the parents indicates a need for further teaching?

7 : The nurse is evaluating the home care plan for a I-year-old diagnosed with phenylketonuria. Which action by the parents indicates a need for further teaching?

8 : A parent expresses concern that their 3-year-old is still having frequent temper tantrums. Which of the following should the nurse emphasize when responding to the parent?

9 : The nurse is teaching a group of parents about the developmental milestones in preadolescent children. Which of the following should the nurse emphasize as an important milestone for 9-year-old girls?

10 : The nurse is educating the parents of a 2-week-old infant who has been diagnosed with phenylketonuria (PKU) after a positive metabolic screening. Which of the following is the most important dietary instruction to prevent long-term neurological damage?

1 :
The nurse is preparing to screen a child for developmental delays. What is the most appropriate action by the nurse prior to assessing motor skills?

2 :
The nurse is preparing to provide post-mortem care for a 7-year-old child who has died after a prolonged illness. Which action should the nurse take first to support the family during this time?

3 :
The nurse assesses a 10-year-old child whose mother expresses concern about the child's weight. The child is overweight, and the mother is unsure about how to help the child. What is the first step the nurse should take to assess the child's weight status?

4 :
The nurse is assessing an adolescent client's development. Which statement by the adolescent indicates appropriate psychosocial development for their age group?

5 :
A 6-year-old child with a chronic illness practices Buddhism. The parents inform the nurse that their child observes specific meditation and prayer times daily for spiritual healing. How should the nurse best incorporate this practice into the child's care plan?

6 :
The nurse is evaluating the home care plan for a I-year-old diagnosed with phenylketonuria. Which action by the parents indicates a need for further teaching?

7 :
The nurse is evaluating the home care plan for a I-year-old diagnosed with phenylketonuria. Which action by the parents indicates a need for further teaching?

8 :
A parent expresses concern that their 3-year-old is still having frequent temper tantrums. Which of the following should the nurse emphasize when responding to the parent?

9 :
The nurse is teaching a group of parents about the developmental milestones in preadolescent children. Which of the following should the nurse emphasize as an important milestone for 9-year-old girls?

10 :
The nurse is educating the parents of a 2-week-old infant who has been diagnosed with phenylketonuria (PKU) after a positive metabolic screening. Which of the following is the most important dietary instruction to prevent long-term neurological damage?