3rd Edition by Jean Foret Giddens
FULLY COVERED CHAPTERS 1-57
WITH DETAILED EXPLANATIONS
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, Concept 01: Development
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.
CORRECT ANSWER: 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.
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OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance
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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
a. concrete operational.
b. formal operational.
c. preoperational.
d. sensorimotor.
CORRECT ANSWER: 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
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,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. CORRECT ANSWER: D
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.
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b. identifies a need for physical therapy.
c. is a developmental screening tool.
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d. provides a framework for health teaching.
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CORRECT ANSWER: 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 and 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).
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, d. failure to thrive.
CORRECT ANSWER: 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. CORRECT ANSWER: C
Function is one of the concepts most significantly impacted by development. Others include sensory-
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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
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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.
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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.
CORRECT ANSWER: 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
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