The nurse is performing a cognitive assessment of a 2-year-old. Which behavior would alert the nurse to a developmental delay in this child?
The child does not point to named body parts.
The child cannot say name, age, and gender.
The child cannot follow a series of two independent commands.
The child has a vocabulary of 40 to 50 words.
The Correct Answer is A
A. The child does not point to named body parts. By the age of 2, most children can point to at least two body parts when asked. This ability indicates that the child understands and can process verbal instructions, which is a key cognitive milestone.
B. The child cannot say name, age, and gender. While knowing their name, age, and gender is important, it is more typical for children to achieve this milestone closer to 3 years old. Therefore, this would not necessarily indicate a developmental delay at 2 years.
C. The child cannot follow a series of two independent commands. By 2 years old, children should be able to follow simple two-step commands, such as "Pick up the toy and give it to me." This ability demonstrates their understanding and processing of sequential instructions.
D. The child has a vocabulary of 40 to 50 words. A vocabulary of 40 to 50 words is within the normal range for a 2-year-old. Most children at this age are expected to have a vocabulary of at least 50 words and start combining them into simple sentences.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Echolalia refers to the repetition of words or phrases without understanding their meanings and is not what the child is demonstrating.
B. Telegraphic speech is a common speech pattern in toddlers where they use short, concise sentences omitting articles and other nonessential words, as seen in the child's statement "Want go potty."
C. Stuttering involves disruptions in the flow of speech, such as repetitions or prolongations of sounds, which is different from the broken speech patterns observed in telegraphic speech.
D. There's no indication of a developmental delay based on the child's speech pattern, so consulting a speech therapist might not be warranted at this stage.
Correct Answer is C
Explanation
A. Notifying the doctor if fever persists despite acetaminophen is appropriate and shows understanding of when to seek medical guidance.
B. Encouraging frequent intake of water or sugar-free fluids helps prevent dehydration and supports metabolic stability during illness.
C. Checking blood sugar only twice daily is insufficient for a child with type 1 diabetes who is ill. Illness increases the risk of hyperglycemia and diabetic ketoacidosis, so blood glucose should be monitored every 3–4 hours during illness to ensure timely insulin adjustments.
D. Reporting changes in breathing or signs of confusion is appropriate because these can indicate worsening infection or metabolic complications, which require prompt intervention.
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