,Concept 01: Development
| |
Giddens: Concepts for Nursing Practice, 3rd Edition
| | | | | |
MULTIPLE CHOICE |
1. The nurse manager of a pediatric clinic could confirm that the new nurse
| | | | | | | | | | | |
recognized the purpose of the HEADSS Adolescent Risk Profile when the new
| | | | | | | | | | | |
nurse responds that it is used to assess for needs related to
| | | | | | | | | | | |
a. anticipatory guidance. |
b. low-risk adolescents. |
c. physical development. |
d. sexual development. |
ANS: A
The HEADSS Adolescent Risk Profile is a psychosocial assessment screening tool
| | | | | | | | | |
which assesses home, education, activities, drugs, sex, and suicide for the purpose
| | | | | | | | | | | |
of identifying high-risk adolescents 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 is assessed using physical examination.
| | | | | |
OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance | | | | | | |
2. The nurse preparing a teaching plan for a preschooler knows that, according to
| | | | | | | | | | | |
Piaget, the expected stage of development for a preschooler is
| | | | | | | | | |
a. concrete operational. |
b. formal operational. N |
c. preoperational.
d. sensorimotor.
ANS: C
The expected stage of development for a preschooler (3–4 years old) is pre-
| | | | | | | | | | | |
operational. Concrete operational describes the thinking of a school-age child (7–
| | | | | | | | | | |
11 years old). Formal operational describes the thinking of an individual after
| | | | | | | | | | |
about 11 years of age. Sensorimotor describes the earliest pattern of thinking from
| | | | | | | | | | | | |
birth to 2 years old.
| | | | |
OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance | | | | | | |
3. The school nurse talking with a high school class about the difference
| | | | | | | | | | |
between growth and development would best describe growth as
| | | | | | | | |
a. processes by which early cells specialize. | | | | |
b. psychosocial and cognitive changes. | | |
c. qualitative changes associated with aging. | | | |
d. quantitative changes in size | | |
| or weight. ANS: D
| |
WWW.NURSYLAB.COM
, Growth is a quantitative change in which an increase in cell number and size
| | | | | | | | | | | | |
results in an increase in overall size or weight of the body or any of its parts.
| | | | | | | | | | | | | | | |
|The processes by which early cells specialize are referred to as differentiation.
| | | | | | | | | | |
Psychosocial and cognitive changes are referred to as development. Qualitative | | | | | | | | |
changes associated with aging are referred to as maturation.
| | | | | | | | |
OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance | | | | | | |
4. The most appropriate response of the nurse when a mother asks what the
| | | | | | | | | | | |
|Denver II does is that it | | | | |
a. can diagnose developmental disabilities. | | |
b. identifies a need for physical therapy. | | | | |
c. is a developmental screening tool.
| | | |
d. provides a framework for health teaching. | | | | |
ANS: C
The Denver II is the most commonly used measure of developmental status
| | | | | | | | | | |
|used by healthcare professionals; it is a screening tool. Screening tools do not
| | | | | | | | | | | |
|provide a diagnosis. Diagnosis requires a thorough neurodevelopment history and
| | | | | | | | |
|physical examination. |
Developmental delay, which is suggested by screening, is a symptom, not a diagnosis. | | | | | | | | | | | |
The need for any therapy would be identified with a comprehensive evaluation, not a screening
| | | | | | | | | | | | | | |
tool. Some providers use the Denver II as a framework for teaching about expected
| | | | | | | | | | | | | |
|development, but this is not the primary purpose of the tool. | | | | | | | | | |
OBJ: | | NCLEX Client Needs Category: Health Promotion and Maintenance | | | | | | |
5. To plan early intervention anNd care for an infant with Down syndrome, the nurse
| | | | | | | | | | | | | | |
considers knowledge of other physical development exemplars such as
| | | | | | | | |
a. cerebral palsy. |
b. autism.
c. attention-deficit/hyperactivity disorder (ADHD). | |
d. failure to thrive. | |
ANS: D | |
Failure to thrive is also a physical development exemplar. Cerebral palsy is an
| | | | | | | | | | | |
exemplar of motor/developmental delay. Autism is an exemplar of
| | | | | | | | |
social/emotional developmental delay. ADHD is an exemplar of a cognitive
| | | | | | | | | |
disorder.
|
OBJ: | | NCLEX Client Needs Category: Health Promotion and Maintenance | | | | | | |
6. To plan early intervention and care for a child with a developmental delay, the
| | | | | | | | | | | | |
nurse would consider knowledge of the concepts most significantly impacted by
| | | | | | | | | | |
development, including
| |
a. culture.
b. environment.
c. functional status. |
d. nutrition.
| ANS: C |
, Function is one of the concepts most significantly impacted by development. Others
| | | | | | | | | | |
include sensory-perceptual, cognition, mobility, reproduction, and sexuality.
| | | | | | |
Knowledge of these concepts can help the nurse anticipate areas that need to be | | | | | | | | | | | | |
|addressed. Culture is a concept that is considered to significantly affect | | | | | | | | | |
development; the difference is the concepts that affect development are those that
| | | | | | | | | | | |
represent major influencing factors (causes); hence determination of development
| | | | | | | | |
would be the focus of preventive interventions. Environment is considered to
| | | | | | | | | | |
significantly affect development. Nutrition is considered to significantly affect
| | | | | | | | |
development.
|
OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance | | | | | | |
7. A mother complains to the nurse at the pediatric clinic that her 4-year-old child
| | | | | | | | | | | | |
|always talks to her toys and makes up stories. The mother wants her child to
| | | | | | | | | | | | | |
|have a psychological evaluation. The nurse’s best initial response is to
| | | | | | | | | |
a. refer the child to a psychologist immediately.| | | | | |
b. explain that playing make believe is normal at this age. | | | | | | | | |
c. complete a developmental screening using a validated tool. | | | | | | |
d. separate the child from the mother to get more information. | | | | | | | | |
ANS: B
By the end of the fourth year, it is expected that a child will engage in
| | | | | | | | | | | | | | |
fantasy, so this is normal at this age. A referral to a psychologist would be
| | | | | | | | | | | | | | |
premature based only on the complaint of the mother. Completing a
| | | | | | | | | | |
developmental screening would be very appropriate but not the initial response. The
| | | | | | | | | | | |
nurse would certainly want to get more information, but separating the child from
| | | | | | | | | | | | |
the mother is not necessary at this time.
| | | | | | | |
OBJ: NCLEX Client NeedsNCategory: Health Promotion and Maintenance | | | | | |
8. A 17-year-old girl is hospitalized for appendicitis, and her mother asks the nurse
| | | | | | | | | | | |
why she is so needy and acting like a child. The best response of the nurse is
| | | | | | | | | | | | | | | | |
that in the hospital, adolescents
| | | | |
a. have separation anxiety. | |
b. rebel against rules. | |
c. regress because of stress. | | |
d. want to know everything. | | |
ANS: C
Regression to an earlier stage of development is a common response to stress.
| | | | | | | | | | | |
Separation anxiety is most common in infants and toddlers. Rebellion
| | | | | | | | | |
against hospital rules is usually not an issue if the adolescent understands the
| | | | | | | | | | | | |
rules and would not create childlike behaviors. An adolescent may want to “know
| | | | | | | | | | | | |
everything” with their logical thinking and deductive reasoning, but that would not
| | | | | | | | | | | |
explain why they would act like a child.
| | | | | | | |
OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance | | | | | | |
WWW.NURSYLAB.COM
| |
Giddens: Concepts for Nursing Practice, 3rd Edition
| | | | | |
MULTIPLE CHOICE |
1. The nurse manager of a pediatric clinic could confirm that the new nurse
| | | | | | | | | | | |
recognized the purpose of the HEADSS Adolescent Risk Profile when the new
| | | | | | | | | | | |
nurse responds that it is used to assess for needs related to
| | | | | | | | | | | |
a. anticipatory guidance. |
b. low-risk adolescents. |
c. physical development. |
d. sexual development. |
ANS: A
The HEADSS Adolescent Risk Profile is a psychosocial assessment screening tool
| | | | | | | | | |
which assesses home, education, activities, drugs, sex, and suicide for the purpose
| | | | | | | | | | | |
of identifying high-risk adolescents 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 is assessed using physical examination.
| | | | | |
OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance | | | | | | |
2. The nurse preparing a teaching plan for a preschooler knows that, according to
| | | | | | | | | | | |
Piaget, the expected stage of development for a preschooler is
| | | | | | | | | |
a. concrete operational. |
b. formal operational. N |
c. preoperational.
d. sensorimotor.
ANS: C
The expected stage of development for a preschooler (3–4 years old) is pre-
| | | | | | | | | | | |
operational. Concrete operational describes the thinking of a school-age child (7–
| | | | | | | | | | |
11 years old). Formal operational describes the thinking of an individual after
| | | | | | | | | | |
about 11 years of age. Sensorimotor describes the earliest pattern of thinking from
| | | | | | | | | | | | |
birth to 2 years old.
| | | | |
OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance | | | | | | |
3. The school nurse talking with a high school class about the difference
| | | | | | | | | | |
between growth and development would best describe growth as
| | | | | | | | |
a. processes by which early cells specialize. | | | | |
b. psychosocial and cognitive changes. | | |
c. qualitative changes associated with aging. | | | |
d. quantitative changes in size | | |
| or weight. ANS: D
| |
WWW.NURSYLAB.COM
, Growth is a quantitative change in which an increase in cell number and size
| | | | | | | | | | | | |
results in an increase in overall size or weight of the body or any of its parts.
| | | | | | | | | | | | | | | |
|The processes by which early cells specialize are referred to as differentiation.
| | | | | | | | | | |
Psychosocial and cognitive changes are referred to as development. Qualitative | | | | | | | | |
changes associated with aging are referred to as maturation.
| | | | | | | | |
OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance | | | | | | |
4. The most appropriate response of the nurse when a mother asks what the
| | | | | | | | | | | |
|Denver II does is that it | | | | |
a. can diagnose developmental disabilities. | | |
b. identifies a need for physical therapy. | | | | |
c. is a developmental screening tool.
| | | |
d. provides a framework for health teaching. | | | | |
ANS: C
The Denver II is the most commonly used measure of developmental status
| | | | | | | | | | |
|used by healthcare professionals; it is a screening tool. Screening tools do not
| | | | | | | | | | | |
|provide a diagnosis. Diagnosis requires a thorough neurodevelopment history and
| | | | | | | | |
|physical examination. |
Developmental delay, which is suggested by screening, is a symptom, not a diagnosis. | | | | | | | | | | | |
The need for any therapy would be identified with a comprehensive evaluation, not a screening
| | | | | | | | | | | | | | |
tool. Some providers use the Denver II as a framework for teaching about expected
| | | | | | | | | | | | | |
|development, but this is not the primary purpose of the tool. | | | | | | | | | |
OBJ: | | NCLEX Client Needs Category: Health Promotion and Maintenance | | | | | | |
5. To plan early intervention anNd care for an infant with Down syndrome, the nurse
| | | | | | | | | | | | | | |
considers knowledge of other physical development exemplars such as
| | | | | | | | |
a. cerebral palsy. |
b. autism.
c. attention-deficit/hyperactivity disorder (ADHD). | |
d. failure to thrive. | |
ANS: D | |
Failure to thrive is also a physical development exemplar. Cerebral palsy is an
| | | | | | | | | | | |
exemplar of motor/developmental delay. Autism is an exemplar of
| | | | | | | | |
social/emotional developmental delay. ADHD is an exemplar of a cognitive
| | | | | | | | | |
disorder.
|
OBJ: | | NCLEX Client Needs Category: Health Promotion and Maintenance | | | | | | |
6. To plan early intervention and care for a child with a developmental delay, the
| | | | | | | | | | | | |
nurse would consider knowledge of the concepts most significantly impacted by
| | | | | | | | | | |
development, including
| |
a. culture.
b. environment.
c. functional status. |
d. nutrition.
| ANS: C |
, Function is one of the concepts most significantly impacted by development. Others
| | | | | | | | | | |
include sensory-perceptual, cognition, mobility, reproduction, and sexuality.
| | | | | | |
Knowledge of these concepts can help the nurse anticipate areas that need to be | | | | | | | | | | | | |
|addressed. Culture is a concept that is considered to significantly affect | | | | | | | | | |
development; the difference is the concepts that affect development are those that
| | | | | | | | | | | |
represent major influencing factors (causes); hence determination of development
| | | | | | | | |
would be the focus of preventive interventions. Environment is considered to
| | | | | | | | | | |
significantly affect development. Nutrition is considered to significantly affect
| | | | | | | | |
development.
|
OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance | | | | | | |
7. A mother complains to the nurse at the pediatric clinic that her 4-year-old child
| | | | | | | | | | | | |
|always talks to her toys and makes up stories. The mother wants her child to
| | | | | | | | | | | | | |
|have a psychological evaluation. The nurse’s best initial response is to
| | | | | | | | | |
a. refer the child to a psychologist immediately.| | | | | |
b. explain that playing make believe is normal at this age. | | | | | | | | |
c. complete a developmental screening using a validated tool. | | | | | | |
d. separate the child from the mother to get more information. | | | | | | | | |
ANS: B
By the end of the fourth year, it is expected that a child will engage in
| | | | | | | | | | | | | | |
fantasy, so this is normal at this age. A referral to a psychologist would be
| | | | | | | | | | | | | | |
premature based only on the complaint of the mother. Completing a
| | | | | | | | | | |
developmental screening would be very appropriate but not the initial response. The
| | | | | | | | | | | |
nurse would certainly want to get more information, but separating the child from
| | | | | | | | | | | | |
the mother is not necessary at this time.
| | | | | | | |
OBJ: NCLEX Client NeedsNCategory: Health Promotion and Maintenance | | | | | |
8. A 17-year-old girl is hospitalized for appendicitis, and her mother asks the nurse
| | | | | | | | | | | |
why she is so needy and acting like a child. The best response of the nurse is
| | | | | | | | | | | | | | | | |
that in the hospital, adolescents
| | | | |
a. have separation anxiety. | |
b. rebel against rules. | |
c. regress because of stress. | | |
d. want to know everything. | | |
ANS: C
Regression to an earlier stage of development is a common response to stress.
| | | | | | | | | | | |
Separation anxiety is most common in infants and toddlers. Rebellion
| | | | | | | | | |
against hospital rules is usually not an issue if the adolescent understands the
| | | | | | | | | | | | |
rules and would not create childlike behaviors. An adolescent may want to “know
| | | | | | | | | | | | |
everything” with their logical thinking and deductive reasoning, but that would not
| | | | | | | | | | | |
explain why they would act like a child.
| | | | | | | |
OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance | | | | | | |
WWW.NURSYLAB.COM
