Practice Question
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.)
Answer Choices:
Correct Answer:
The child is unable to follow simple two-step instructions.
Rationale:
✅ B. The child is unable to follow simple two-step instructions
🟢 Following multi-step instructions is an expected developmental skill for a 4-year-old. Lack of this ability signals a possible cognitive or language processing delay.
🟢 At this stage, children should be able to follow directions like “Go to your room and get your shoes,” which requires attention span, memory, and understanding.
🟢 This deficit may interfere with learning readiness, including classroom instructions and peer interaction.
🟢 Referral allows early intervention by speech-language pathologists or developmental specialists.
🟢 Early diagnosis improves outcomes through tailored therapy, enhancing social and academic success.
✅ D. The child has a vocabulary of fewer than 50 words
🟢 A vocabulary under 50 words is significantly below the expected range for a 4-year-old, who should typically know over 1,000 words.
🟢 Such a limitation indicates a language delay, possibly stemming from hearing impairment, neurological disorders, or autism spectrum disorder.
🟢 Language deficits at this age can hinder expressive communication and affect social and emotional development.
🟢 Without intervention, children may struggle with literacy skills and face delays in academic achievement.
🟢 Early referral ensures access to speech therapy, audiology assessments, and parental coaching.
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This question is from RN ATI Pediatrics Exam VII which contains 66 questions.
More Questions from This Exam
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A nurse is conducting a health history assessment on a pediatric patient newly admitted to the pediatric floor. Which of the following questions should the nurse include to gather comprehensive information? (Select all that apply.)
Answer Choices:
A nurse is teaching a class about expected developmental milestones in 2-year-old toddlers. The nurse should include which of the following milestones?
Answer Choices:
Question Details
- Category: RN Nursing Exam(s)
- Subcategory: ATI Exam(s)
- Domain: RN ATI Pediatrics
- Answer Choices: 5