The nurse is performing the Denver II screening test on a ...

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The nurse is performing the Denver II screening test on a 12-month-old infant during a routine well-child visit. The nurse should tell the infant's parents that the Denver II:
 
  a. Tests three areas of development: cognitive, physical, and psychological
  b. Will indicate whether the child has a speech disorder so that treatment can begin.
  c. Is a screening instrument designed to detect children who are slow in development.
  d. Is a test to determine intellectual ability and may indicate whether problems will develop later in school.

Question 2

The nurse is performing a mental status assessment on a 5-year-old girl. Her parents are undergoing a bitter divorce and are worried about the effect it is having on their daughter. Which action or statement might lead the nurse to be concerned about the
 
  girl's mental status?
  a.
  She clings to her mother whenever the nurse is in the room.
  b.
  She appears angry and will not make eye contact with the nurse.
  c.
  Her mother states that she has begun to ride a tricycle around their yard.
  d.
  Her mother states that her daughter prefers to play with toddlers instead of kids her own age while in daycare.

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Answer to Question 1

ANS: C
The Denver II is a screening instrument designed to detect developmental delays in infants and preschoolers. It tests four functions: gross motor, language, fine motor-adaptive, and personal-social. The Denver II is not an intelligence test; it does not predict current or future intellectual ability. It is not diagnostic; it does not suggest treatment regimens.

Answer to Question 2

ANS: D
The mental status assessment of infants and children covers behavioral, cognitive, and psychosocial development and examines how the child is coping with his or her environment. Essentially, the nurse should follow the same Association for Behavioral and Cognitive Therapies (ABCT) guidelines as those for the adult, with special consideration for developmental milestones. The best examination technique arises from a thorough knowledge of the developmental milestones (described in Chapter 2). Abnormalities are often problems of omission (e.g., the child does not achieve a milestone as expected).

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