b b
Giddens:ConceptsforNursingPractice,3rdEdition
b b b b b b
MULTIPLECHOICE b
1. The nurse manager of a pediatric clinic could confirm that the new nurse recognized the
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purpose of the HEADSS Adolescent Risk Profile when the new nurse responds that it is used to
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assess for needs related to
b b b b b
a. anticipatoryguidance. b
b. low-risk adolescents. b
c. physical development. b
d. sexual development. b
ANS: A b
The HEADSS Adolescent Risk Profile is a psychosocial assessment screening tool which
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assesses home, education, activities, drugs, sex, and suicide for the purpose of identifying high-
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risk adolescents and the need for anticipatory guidance. It is used to identify high-risk, not low-
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risk, adolescents. Physical development is assessed with anthropometric data.
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Sexual development is assessed using physical examination.
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OBJ: NCLEXClient Needs Category: HealthPromotion andMaintenance b b b b b b b
2. Thenursepreparing a teaching plan fora preschooler knows that, according to Piaget, the
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expected stage of development for a preschooler is
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a. concreteoperational. b
b. formaloperational. N b
c. preoperational.
d. sensorimotor.
ANS: C b
The expected stage of development for a preschooler (3–4 years old) is pre-operational. Concrete
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operational describes the thinking of a school-age child (7–11 years old). Formal operational
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describes the thinking of an individual after about 11 years of age. Sensorimotor describes the
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earliest pattern of thinking from birth to 2 years old.
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OBJ: NCLEXClient Needs Category: Health Promotion andMaintenance b b b b b b b
3. Theschool nursetalking with a high school class about the differencebetween growth and
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development would best describe growth as
b b b b b b
a. processesby which early cells specialize. b b b b b
b. psychosocial and cognitivechanges. b b b
c. qualitative changes associated with aging. b b b b
d. quantitativechangesinsizeorweight. b b b b b
bANS: D b
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, Growth is a quantitative change in which an increase in cell number and size results in an increase
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in overall size or weight of the body or any of its parts. The processes by which early cells specialize
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are referred to as differentiation. Psychosocial and cognitive changes arereferred to as
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development. Qualitative changes associated with aging arereferred to as maturation.
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OBJ: NCLEXClient Needs Category: HealthPromotion andMaintenance b b b b b b b
4. Themost appropriate response of thenurse when a mother asks what the Denver IIdoes is that it
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a. can diagnose developmental disabilities.
b b b
b. identifies aneed for physical therapy. b b b b b
c. is a developmental screening tool.
b b b b
d. provides aframework for health teaching. b b b b b
ANS: C b
The Denver II is the most commonly used measure of developmental status used by healthcare
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professionals; it is a screening tool. Screening tools do not provideadiagnosis. Diagnosis requires a
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thorough neurodevelopment history and physical examination.
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Developmental delay, which is suggested by screening, is a symptom, not a diagnosis. The need for b b b b b b b b b b b b b b b
any therapy would be identified with a comprehensive evaluation, not a screening tool. Some
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providers use the Denver II as a framework for teaching about expected development, but this is not
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the primary purpose of the tool.
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OBJ: NCLEXClientNeeds Category: HealthPromotion andMaintenance b b b b b b b
5. Toplanearlyinterventiona n Nd careforaninfantwithDownsyndrome,thenurseconsiders
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knowledge of other physical development exemplars such as
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a. cerebralpalsy. b
b. autism.
c. attention-deficit/hyperactivitydisorder(ADHD). b b
d. failureto thrive. b b
ANS: D b
Failureto thriveis also a physical development exemplar. Cerebral palsy is an exemplar of
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motor/developmental delay. Autism is an exemplar of social/emotional developmental delay.
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ADHD is an exemplar of a cognitive disorder.
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OBJ: NCLEXClient Needs Category: HealthPromotion andMaintenance b b b b b b b
6. To plan early intervention and care for a child with a developmental delay, the nurse would
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considerknowledgeoftheconcepts most significantlyimpactedby development, including
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a. culture.
b. environment.
c. functionalstatus. b
d. nutrition.
bANS: C b
, Function is oneof the concepts most significantly impacted by development. Others include
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sensory-perceptual, cognition, mobility, reproduction, and sexuality. Knowledge of these
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concepts can help the nurse anticipate areas that need to be addressed. Culture is a concept that is
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considered to significantly affect development; the difference is the concepts that affect
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development are those that represent major influencing factors (causes); hence determination of
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development would be the focus of preventive interventions. Environment is considered to
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significantly affect development. Nutrition is considered to significantly affect development.
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OBJ: NCLEXClient Needs Category: HealthPromotion andMaintenance b b b b b b b
7. A mothercomplains to the nurse at the pediatric clinic that her4-year-old child always talks to her
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toys and makes up stories. The mother wants her child to have a psychological evaluation. The
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nurse’s best initial response is to
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a. refer the child to a psychologist immediately. b b b b b b
b. explain that playing makebelieve is normal at this age. b b b b b b b b b
c. completeadevelopmental screening using a validated tool. b b b b b b b
d. separatethe child from the mother toget moreinformation. b b b b b b b b b
ANS: B b
By the end of the fourth year, it is expected that a child will engage in fantasy, so this is normal at this
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age. A referral to a psychologist would be premature based only on the complaint of themother.
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Completing adevelopmental screening would be very appropriate but not the initial response. The
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nurse would certainly want to get more information, but separating the child from the mother is not
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necessary at this time.
b b b b
OBJ: NCLEXClientNeedsNCategory: HealthPromotionandMaintenance b b b b b b
8. A 17-year-old girl is hospitalized forappendicitis, and her mother asks the nurse why sheis so
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needy and acting like a child. The best response of the nurse is that in the hospital, adolescents
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a. haveseparation anxiety. b b
b. rebelagainst rules. b b
c. regress becauseofstress. b b b
d. want to know everything. b b b
ANS: C b
Regression to an earlier stage of development is a common response to stress. Separation anxiety is
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most common in infants and toddlers. Rebellion against hospital rules is usually not an issue ifthe
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adolescent understands the rules and would not create childlikebehaviors. An adolescent may
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want to “know everything” with their logical thinking and deductive reasoning, but that would not
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explain why they would act like a child.
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OBJ: NCLEXClient Needs Category: HealthPromotion andMaintenance b b b b b b b
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