A nurse is conducting a developmental assessment on a 5-year… | 마이메르시 MyMerci
Child Health
문제

A nurse is conducting a developmental assessment on a 5-year-old child suspected of having intellectual disability. Which assessment finding would be most indicative of intellectual disability in this child?

해설
Intellectual disability is defined by significant limitations in intellectual functioning and adaptive behavior. A 6-year-old primarily communicating with single words and gestures indicates severe deficits in both areas, meeting diagnostic criteria. Other options describe common developmental variations (e.g., riding a bike, solitary play, distractibility) not definitive for intellectual disability.

심화 해설

Core Nursing Explanation Key Concept Analysis: This question assesses the nurse's ability to recognize the core diagnostic criteria for Intellectual Disability (ID) in a pediatric developmental assessment. ID is characterized by significant deficits in intellectual functioning (e.g., reasoning, problem-solving) and adaptive behavior (conceptual, social, and practical skills). The diagnosis requires that these limitations manifest during the developmental period (before age 18). A 5-year-old is expected to have developed complex language skills, including multi-word sentences and basic conversational ability.

Answer Rationale: Key Point! Option ② is correct because it directly points to a severe deficit in adaptive behavior, specifically in the conceptual domain (language). A typical 5-year-old should be speaking in complete, complex sentences, telling stories, and using a large vocabulary. Communicating primarily through single words and gestures is more consistent with the language level of a much younger toddler (around 18-24 months). This significant delay, especially when combined with deficits in intellectual functioning, is a hallmark indicator of ID.

Distractor Analysis:
Watch out for confusion! Option ① describes a mixed skill profile. The inability to tie shoelaces is common for a 5-year-old (fine motor skill still developing), while riding a bike with training wheels is an age-appropriate gross motor skill. This does not indicate a global deficit.
Option ③ describes a social preference (solitary play). While social skills can be affected in ID, preferring to play alone is also common in children with Autism Spectrum Disorder (ASD) or can be a normal temperamental variation. It is not a definitive sign of ID on its own.
Option ④ describes behaviors consistent with Attention-Deficit/Hyperactivity Disorder (ADHD), such as inattention and distractibility. While ADHD and ID can co-occur, hyperactivity and distractibility are not core diagnostic criteria for intellectual disability.

Related Concepts: Developmental assessment uses standardized tools (e.g., Denver II) to screen for delays. A formal diagnosis of ID involves psychological testing (IQ < 70) and assessment of adaptive functioning. Nursing care focuses on supporting the child's strengths, facilitating communication, promoting independence in self-care, and providing family education and resources.

Concept Summary
ConceptKey Points
Intellectual Disability (ID)Deficits in intellectual & adaptive functioning originating in developmental period.
Adaptive Behavior DomainsConceptual (language, academics), Social (empathy, relationships), Practical (self-care, routines).
Developmental Milestone: Age 5Speaks in full sentences, tells stories, dresses/undresses, hops on one foot.
Nursing RoleDevelopmental screening, family support, care coordination, promoting optimal functioning.

Side-by-Side Comparison!
ConditionCore FeatureDevelopmental Presentation (Age 5 Example)
Intellectual Disability (ID)Global delays in cognitive & adaptive skills.Uses single words/gestures; cannot follow simple 2-step commands.
Autism Spectrum Disorder (ASD)Deficits in social communication & restricted/repetitive behaviors.May have advanced vocabulary but lacks social reciprocity; engages in stereotyped play.
Attention-Deficit/Hyperactivity Disorder (ADHD)Persistent inattention and/or hyperactivity-impulsivity.Cannot sit still, easily distracted, but language and cognitive skills are age-appropriate.
Specific Learning DisorderDifficulty in a specific academic area (e.g., reading, math).Struggles with pre-reading skills but has normal conversational language and social skills.

Anatomy, Physiology & Pharmacology Points While ID is a neurodevelopmental disorder, understanding related physiology is key. It often involves atypical brain development affecting the cerebral cortex and neural connectivity. Causes can be prenatal (e.g., Down syndrome, fetal alcohol syndrome), perinatal (birth asphyxia), or postnatal (severe head injury). There is no medication to treat ID itself, but pharmacotherapy may be used to manage co-occurring conditions like ADHD, seizures, or mood disorders.

Memory Tips ID = "I Delay": Think of Intellectual and Daptive delays. For a 5-year-old, remember the "5 S's" they should be able to do: Speak in sentences, Skip, Swing, Stay dressed, and follow Simple rules in games. Missing multiple "S's," especially speech, is a red flag.

High-Frequency NCLEX Topics The NCLEX frequently tests the nurse's ability to differentiate between normal developmental variations and signs of a true disorder. You must know age-expected milestones. Questions often present a child's behavior and ask you to identify the most concerning finding or the priority nursing action (e.g., "Which finding should be reported to the primary care provider?").

Watch Out for Question Variations! * Symptom Identification → Priority Intervention: "The nurse notes a 5-year-old communicates with single words. Which action should the nurse take first?" (Answer: Document the finding and refer for a comprehensive developmental evaluation). * Parent Teaching: "A parent of a child with intellectual disability says, 'I just want him to be normal.' Which response by the nurse is best?" (Answer: Focus on the child's strengths and achievable goals). * Differentiating Disorders: The same scenario could ask you to choose between ID, ASD, and Global Developmental Delay based on subtle clues in the presentation.

임상 시나리오

Nursing Clinical Practice Guide Clinical Scenario: You are a pediatric clinic nurse. During a well-child visit for a 5-year-old named Leo, his mother expresses concern that he is not talking like other children his age. He points and uses words like "juice" or "up," but does not combine words. He plays contentedly by himself, stacking blocks for long periods.

Nursing Intervention Strategy: 1. Assessment: Use a structured developmental screening tool (e.g., Ages & Stages Questionnaire, ASQ-3). Observe Leo's play, interaction with his mother, and attempt to engage him in simple conversation. Obtain a detailed birth and developmental history. 2. Nursing Diagnosis: Impaired Verbal Communication related to developmental delay. 3. Planning & Implementation: * Communicate Findings: Report your objective observations (e.g., "Uses

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