A nurse is assessing a 4-year old preschooler. Which of the following findings should indicate to the nurse a need to refer the child for a possible developmental delay? (Select all that apply.)
The child occasionally reverses letters when writing.
The child is unable to follow simple two-step instructions.
The child occasionally stutters when excited or nervous.
The child has a vocabulary of fewer than 50 words
The child has difficulty sharing toys with peers
Correct Answer : B,D
A. Occasional letter reversal is common at this age and not a concern for developmental delay.
B. At 4 years old, a child should be able to follow simple two-step instructions. Difficulty doing so may indicate a developmental delay.
C. Occasional stuttering when excited or nervous is common and does not indicate a developmental delay.
D. A vocabulary of fewer than 50 words is concerning, as children at this age typically have a much larger vocabulary.
E. Difficulty sharing toys is developmentally normal for a 4-year-old and does not necessarily indicate a delay.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. While this response reassures the child that they are good, it does not directly address the magical thinking that surgery is a punishment.
B. Telling the child not to think a certain way dismisses their feelings and does not validate their emotions.
C. This response acknowledges the child's feelings (validating their emotional response) and corrects the misconception by explaining that surgery is for their health, not punishment.
D. Offering toys may distract the child, but it does not help address the root of their fear and magical thinking.
Correct Answer is A
Explanation
A. A facial grimace is a common indicator of pain in infants and suggests discomfort, prompting further assessment.
B. Dry palms and feet are not specific indicators of pain and can be influenced by other factors such as dehydration or environmental conditions.
C. Wide-open eyes in an infant can occur for various reasons, including curiosity or surprise, and are not specifically indicative of pain.
D. Decreased muscle tone can indicate various conditions, but it is not a direct sign of pain and may require further evaluation.
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