MULTIPLECHOICE
1. Thenursemanager ofapediatriccliniccouldconfirmthatthenewnurserecognizedthepurposeof the
HEADSS Adolescent Risk Profile when the new nurse responds that it is used to assess
forneedsrelatedto
a. anticipatoryguidance.
b. low-riskadolescents.
c. physicaldevelopment.
d. sexualdevelopment.
ANS:A
TheHEADSSAdolescentRiskProfileisapsychosocialassessmentscreeningtoolwhichassesseshome,
education, activities, drugs, sex, and suicide for the purpose of identifying high-riskadolescents and
the need for anticipatory guidance. It is used to identify high-risk, not low-risk,adolescents. Physical
development is assessed with anthropometric data. Sexual development
isassessedusingphysicalexamination.
REF:6OBJ:NCLEXClientNeedsCategory:HealthPromotionandMaintenance
2. Thenursepreparingateachingplanforapreschoolerknowsthat,accordingtoPiaget,theexpecte
dstageofdevelopmentforapreschooleris
a. concreteoperational.
b. formaloperational.
c. preoperational.
d. sensorimotor.
ANS:C
Theexpectedstageofdevelopmentforapreschooler (3to4yearsold)ispreoperational.
Concreteoperationaldescribesthethinkingofaschool-age child (7to11yearsold).Formaloperational
,AdvancedPracticeNursing:EssentialsforRoleDevelopment4thEditionJoelTestBank
describesthethinking ofan individualafter about11 yearsofage.Sensorimotor
describestheearliestpatternofthinkingfrombirthto2years old.
REF:5OBJ:NCLEXClientNeedsCategory:HealthPromotionandMaintenance
3. Theschoolnursetalking withahighschoolclassabout
thedifferencebetweengrowthanddevelopmentwouldbestdescribegrowthas
a. processesbywhichearlycellsspecialize.
b. psychosocialandcognitivechanges.
c. qualitativechangesassociatedwithaging.
d. quantitativechanges insizeorweight.
ANS:D
Growthisaquantitative changeinwhichanincreaseincellnumberandsizeresults inanincreasein overall
size or weight of the body or any of its parts. The processes by which early cellsspecialize are
referred to asdifferentiation. Psychosocial and cognitive changes are referred to
asdevelopment.Qualitative changesassociatedwithaging are referredtoasmaturation.
REF:2OBJ:NCLEXClientNeedsCategory:HealthPromotionandMaintenance
4. ThemostappropriateresponseofthenursewhenamotheraskswhattheDenverIIdoesisthatit
a. candiagnosedevelopmentaldisabilities.
b. identifiesaneedforphysicaltherapy.
c. isadevelopmentalscreeningtool.
d. providesaframeworkforhealthteaching.
ANS:C
The Denver II is the most commonly used measure of developmental status used by health
careprofessionals;itisascreeningtool.Screeningtoolsdonotprovideadiagnosis.Diagnosisrequiresathor
ough neurodevelopment history and physical examination. Developmental delay, which
issuggestedbyscreening,isa symptom,notadiagnosis.The needforanytherapywouldbeidentified with
a comprehensive evaluation, not a screening tool. Some providers use the Denver IIas a framework
for teaching about expected development, but this is not the primary purpose of thetool.
,AdvancedPracticeNursing:EssentialsforRoleDevelopment4thEditionJoelTestBank
REF:4OBJ:NCLEXClientNeedsCategory:HealthPromotionandMaintenance
5. Toplanearlyinterventionandcarefor aninfantwithDownsyndrome,
thenurseconsidersknowledge ofotherphysicaldevelopmentexemplars suchas
a. cerebralpalsy.
b. failuretothrive.
c. fetalalcoholsyndrome.
d. hydrocephaly.
ANS:D
Hydrocephalyisalsoaphysicaldevelopmentexemplar.Cerebralpalsyisanexemplar
ofadaptivedevelopmentaldelay.Failuretothriveisanexemplar ofsocial/emotionaldevelopmentaldelay.
Fetalalcoholsyndromeisanexemplarofcognitivedevelopmentaldelay.
REF:9OBJ:NCLEXClientNeedsCategory:HealthPromotionandMaintenance
6. Toplanearlyinterventionandcareforachildwithadevelopmentaldelay,thenursewouldconsider
knowledgeoftheconceptsmostsignificantlyimpactedbydevelopment,including
a. culture.
b. environment.
c. functionalstatus.
d. nutrition.
ANS:C
Function is one of the concepts most significantly impacted by development. Others
includesensory-perceptual, cognition, mobility, reproduction, and sexuality. Knowledge of these
conceptscan help the nurse anticipate areas that need to be addressed. Culture is a concept that is
consideredto significantly affect development; the difference is the concepts that affect
development are thosethatrepresentmajorinfluencing
factors(causes),hencedeterminationofdevelopment andwouldbethe focus of preventive
interventions. Environment is considered to significantly
affectdevelopment.Nutritionisconsideredtosignificantlyaffectdevelopment.
REF:1OBJ:NCLEXClientNeedsCategory:HealthPromotionandMaintenance
, AdvancedPracticeNursing:EssentialsforRoleDevelopment4thEditionJoelTestBank
7. Amother complainstothenurseatthepediatricclinicthather4-year-oldchildalwaystalkstoher toys
and makes up stories. The mother wants her child to have a psychologic evaluation.
Thenursesbestinitialresponseis to
a. referthechildtoapsychologist.
b. explainthatplayingmakebelievewithdollsandpeopleisnormalatthisage.
c. completea developmentalscreening.
d. separatethechildfromthemothertogetmoreinformation.
ANS:B
By the end of the fourth year, it is expected that a child will engage in fantasy, so this is normal
atthis age. A referral to a psychologist would be premature based only on the complaint of
themother. Completing a developmental screening would be very appropriate but not the
initialresponse.Thenursewouldcertainlywanttogetmoreinformation,
butseparatingthechildfromthemotherisnotnecessaryatthis time.
REF:5OBJ:NCLEXClientNeedsCategory:HealthPromotionandMaintenance
8. A17-year-oldgirlishospitalizedforappendicitis,andhermotherasksthenursewhyshe
issoneedyandactinglikeachild. Thebestresponseofthenurseisthatinthehospital, adolescents
a. haveseparationanxiety.
b. rebelagainstrules.
c. regressbecauseofstress.
d. wanttoknoweverything.
ANS:C
Regressiontoanearlier stageofdevelopmentisacommonresponseto stress.Separationanxietyismost
common in infants and toddlers. Rebellion against hospital rules is usually not an issue if
theadolescentunderstandstherulesandwouldnotcreatechildlikebehaviors.Anadolescentmaywantto
know everything with their logical thinking and deductive reasoning, but that would not
explainwhytheywouldactlikeachild.
Chapter2.EmergingRolesoftheAdvancedPracticeNurse