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Giddens: ConceptsforNursing Practice, 3rdEdition
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MULTIPLE CHOICE kyky
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
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used to assess for needs related to
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a. anticipatory guidance. kyky
b. low-risk adolescents. kyky
c. physical development. kyky
d. sexual development. kyky
ANS: A k y k y
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
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high-risk adolescents and the need for anticipatory guidance. It is used to identify high-risk,
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not low-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: NCLEX Client Needs Category: Health Promotion and Maintenance kyky kyky kyky kyky kyky kyky kyky
2. The nurse preparing a teaching plan for a preschooler knows that, according to Piaget, the
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expected stage of development for a preschooler is
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a. concrete operational. kyky
b. formal operational. N kyky
c. preoperational.
d. sensorimotor.
ANS: C k y k y
The expected stage of development for a preschooler (3–4 years old) is pre-operational.
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Concrete operational describes the thinking of a school-age child (7–11 years old). Formal
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operational describes the thinking of an individual after about 11 years of age. Sensorimotor
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describes the earliest pattern of thinking from birth to 2 years old.
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OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance kyky kyky kyky kyky kyky kyky kyky
3. The school nurse talking with a high school class about the difference between growth and
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development would best describe growth as
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a. processes by which early cells specialize. kyky kyky kyky kyky kyky
b. psychosocial and cognitive changes. kyky kyky kyky
c. qualitative changes associated with aging. kyky kyky kyky kyky
d. quantitative changes in size or weight. kyky kyky kyky kyky kyky
ky ky ANS: k y k y D
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, Growth is a quantitative change in which an increase in cell number and size results in an
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increase in overall size or weight of the body or any of its parts. The processes by which early
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cells specialize are referred to as differentiation. Psychosocial and cognitive changes are
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referred to as development. Qualitative changes associated with aging are referred to as
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maturation.
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OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance kyky kyky kyky kyky kyky kyky kyky
4. The most appropriate response of the nurse when a mother asks what the Denver II does is that
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it
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a. can diagnose developmental disabilities. kyky kyky k yk y
b. identifies a need for physical therapy. kyky kyky kyky kyky k yk y
c. is a developmental screening tool.
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d. provides a framework for health teaching. kyky kyky kyky kyky kyk y
ANS: C k y k y
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 provide a diagnosis. Diagnosis
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requires a 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 kyky kyky kyky kyky kyky kyky kyky kyky kyky kyky kyky kyky kyky k yk y
for any therapy would be identified with a comprehensive evaluation, not a screening tool.
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Some providers use the Denver II as a framework for teaching about expected development,
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but this is not the primary purpose of the tool.
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OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance kyky kyky kyky kyky kyky kyky kyky
5. Toplanearlyinterventiona n Nd careforaninfantwithDownsyndrome,thenurseconsiders
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knowledge of other physical development exemplars such as
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a. cerebral palsy. kyky
b. autism.
c. attention-deficit/hyperactivity disorder (ADHD). kyky kyky
d. failureto thrive. kyky kyky
ANS: D k y k y
Failure to thrive is 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
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delay. ADHD is an exemplar of a cognitive disorder.
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OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance kyky kyky kyky kyky kyky kyky kyky
6. To plan early intervention and care for a child with a developmental delay, the nurse would
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consider knowledge of the concepts most significantly impacted by development, including
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a. culture.
b. environment.
c. functional status. kyky
d. nutrition.
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, Function is one of the concepts most significantly impacted by development. Others include kyky kyky kyky kyky kyky kyky kyky kyky kyky kyky kyky kyky
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
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that is considered to significantly affect development; the difference is the concepts that
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affect development are those that represent major influencing factors (causes); hence
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determination of development would be the focus of preventive interventions. Environment
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is considered to significantly affect development. Nutrition is considered to significantly
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affect development.
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OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance kyky kyky kyky kyky kyky kyky kyky
7. A mother complains to the nurse at the pediatric clinic that her 4-year-old child always talks to
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her toys and makes up stories. The mother wants her child to have a psychological evaluation.
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The nurse’s best initial response is to
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a. refer the child to a psychologist immediately. kyky kyky kyky kyky kyky k yky
b. explain that playing make believe is normal at this age. kyky kyky kyky kyky kyky k yky kyky kyky ky ky
c. complete a developmental screening using a validated tool. kyky kyky kyky ky ky ky ky kyky kyky
d. separate the child from the mother to get more information. kyky kyky kyky kyky kyky k yky kyky kyky kyky
ANS: B k y k y
By the end of the fourth year, it is expected that a child will engage in fantasy, so this is normal
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at this age. A referral to a psychologist would be premature based only on the complaint of the
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mother. Completing a developmental screening would be very appropriate but not the initial
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response. The nurse would certainly want to get more information, but separating the child
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from the mother is not necessary at this time.
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OBJ: NCLEXClient NeedsNCategory: Health Promotion and Maintenance ky kyky kyky kyky kyky kyky
8. A 17-year-old girl is hospitalized for appendicitis, and her mother asks the nurse why she is so
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needy and acting like a child. The best response of the nurse is that in the hospital,
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adolescents
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a. have separation anxiety. kyky kyky
b. rebel against rules. kyky kyky
c. regress because of stress. kyky kyky kyky
d. want to know everything. kyky kyky kyky
ANS: C k y k y
Regression to an earlier stage of development is a common response to stress. Separation kyky kyky kyky kyky kyky k yk y k yk y k yk y k yk y k yk y ky ky ky ky k yk y
anxiety is most common in infants and toddlers. Rebellion against hospital rules is usually not
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an issue if the adolescent understands the rules and would not create childlike behaviors. An
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adolescent may want to “know everything” with their logical thinking and deductive
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reasoning, but that would not explain why they would act like a child.
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OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance kyky kyky kyky kyky kyky kyky kyky
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