mm mm mm mm mm mm
mm mm mm mm mm mm mm
mm mm
,Concept 1: Development
ss ss
Test Bank
ss s s
MULTIPLE CHOICE s s
1. The nurse manager of a pediatric clinic could confirm that the new
s s s s s s s s s s s s s s s s s s s s s s
s s nurse recognized the purpose of the HEADSS Adolescent Risk Profile when
s s s s s s ss ss s s ss s s s s s s
ss the new nurse responds that it is used to assess for needs related to
s s s s ss s s s s s s s s s s s s s s s s s s s s
a. anticipatory guidance. ss
b. low-risk adolescents. ss
c. physical development. ss
d. sexual development. ss
ANS: s s s s A
The HEADSS Adolescent Risk Profile is a psychosocial assessment
s s s s s s s s s s s s s s s s
screening tool which assesses home, education, activities, drugs, sex,
s s s s ss s s s s s s s s s s s s
and suicide for the purpose of identifying high-risk adolescents and
s s s s s s s s s s ss s s s s s s s s
the need for anticipatory guidance. It is used to identify high-risk,
s s s s s s s s s s s s s s ss s s s s s s
not low-risk, adolescents. Physical development is assessed with
s s s s s s s s ss s s s s ss
anthropometric data. Sexual development is assessed using physical
s s s s s s s s s s s s s s s s
examination.
ss
REF: 6 OBJ: NCLEX® Client Needs s s s s s s Category: Health Promotion and Maintenance
s s ss s s ss
2. The nurse preparing a teaching plan for a preschooler knows that,
s s s s s s s s s s s s s s s s s s s s
s s according to Piaget, the expected stage of development for a
s s ss s s s s s s s s s s s s s s
s s preschooler is s s
a. concrete operational. s s
b. formal operational. ss
c. preoperational.
d. sensorimotor.
ANS: ss ss C
The expected stage of development for a preschooler (3 to 4 years old)
s s s s s s s s s s s s s s s s s s s s s s s s
is preoperational. Concrete operational describes the thinking of a school-age
s s ss s s ss ss s s s s s s ss ss
child (7 to 11 years old). Formal operational describes the thinking of an
s s s s s s ss s s s s s s s s ss s s s s s s s s
individual after about 11 years of age. Sensorimotor describes the
s s s s s s ss s s s s s s s s s s s s
earliest pattern of thinking from birth to 2 years old.
s s s s s s s s s s s s ss s s s s s s
REF: 5 OBJ: NCLEX® Client Needs s s s s s s Category: Health Promotion and Maintenance
s s ss s s ss
3. The school nurse talking with a high school class about the difference
s s ss ss s s s s s s s s ss s s s s s s
s s between growth and development would best describe growth as
ss s s s s s s s s s s s s s s
a. processes by which early cells specialize. s s ss s s ss s s
b. psychosocial and cognitive changes. ss s s s s
c. qualitative changes associated with aging. s s s s s s ss
d. quantitative changes in size or weight. s s s s s s s s s s
ANS: ss ss D
Growth is a quantitative change in which an increase in cell number
s s s s s s s s s s s s s s s s s s s s s s
and size results in an increase in overall size or weight of the body or
s s s s s s ss s s s s s s s s s s s s s s s s ss s s ss
any of its parts. The processes by which early cells specialize are referred
s s ss s s s s s s s s ss s s s s s s s s s s s s
to as differentiation. Psychosocial and
s s s s s s s s s s
,cognitive changes are referred to as development. Qualitative changes
s s s s s s s s s s s s s s s s
associated with aging are referred to as maturation.
s s ss s s s s s s s s s s s s
, REF: 2 OBJ: NCLEX® Client Needs s s s s s s Category: Health Promotion and Maintenance s s ss s s ss
4. The most appropriate response of the nurse when a mother asks what
s s s s s s s s ss s s s s ss s s s s s s
s s the Denver II does is that it
s s ss s s s s s s s s
a. can diagnose developmental disabilities.
ss s s ss
b. identifies a need for physical therapy. ss ss s s ss ss
c. is a developmental screening tool.
ss s s ss s s
d. provides a framework for health teaching.
s s s s s s s s s s
ANS: ss ss C
The Denver II is the most commonly used measure of developmental
s s s s s s s s s s s s s s s s s s s s
status used by health care professionals; it is a screening tool. Screening
s s s s s s ss s s s s s s s s s s s s s s s s
tools do not provide a diagnosis. Diagnosis requires a thorough
s s s s s s s s s s ss s s s s s s s s
neurodevelopment history and physical examination. Developmental delay,
s s s s s s s s ss s s s s
which is suggested by screening, is a symptom, not a diagnosis. The
s s s s s s s s s s s s s s s s ss s s s s s s
need for any therapy would be identified with a comprehensive evaluation,
s s s s s s s s s s s s s s s s s s s s ss
not a screening tool. Some providers use the Denver II as a
s s s s s s s s s s s s s s s s s s s s s s s s
framework for teaching about expected development, but this is not the
s s ss s s s s s s s s s s s s s s s s s s
primary purpose of the tool.
s s s s mm s s ss
REF: 4 OBJ: NCLEX® Client Needs s s s s s s Category: Health Promotion and Maintenance s s ss s s ss
5. To plan early intervention and care for an infant with Down
ss ss ss s s s s ss s s s s s s ss
syndrome, the nurse considers knowledge of other physical
ss mm s s ss s s s s s s s s
development exemplars such as
s s mm s s s s
a. cerebral palsy. ss
b. failure to thrive. s s s s
c. fetal alcohol syndrome.ss s s
d. hydrocephaly.
ANS: ss ss D
Hydrocephaly is also a physical development exemplar. Cerebral palsy is an
s s ss s s s s ss s s s s ss ss ss
exemplar of adaptive developmental delay. Failure to thrive is an
ss ss s s s s s s s s s s s s s s s s
exemplar of social/emotional developmental delay. Fetal alcohol syndrome is
s s s s ss s s ss mm ss ss s s
an exemplar of cognitive developmental delay.
s s s s s s ss s s mm
REF: 9 OBJ: NCLEX® Client Needs Category: Health Promotion and Maintenance
s s mm s s s s ss ss ss
6. To plan early intervention and care for a child with a developmental delay, the
ss ss mm mm ss ss ss ss ss ss ss ss ss
nurse would consider knowledge of the concepts most significantly impacted by
ss mm mm ss ss ss ss ss ss ss ss
development, including
ss s s
a. culture.
b. environment.
c. functional status. ss
d. nutrition.
ANS: ss ss C
mm mm mm mm mm mm mm
mm mm
,Concept 1: Development
ss ss
Test Bank
ss s s
MULTIPLE CHOICE s s
1. The nurse manager of a pediatric clinic could confirm that the new
s s s s s s s s s s s s s s s s s s s s s s
s s nurse recognized the purpose of the HEADSS Adolescent Risk Profile when
s s s s s s ss ss s s ss s s s s s s
ss the new nurse responds that it is used to assess for needs related to
s s s s ss s s s s s s s s s s s s s s s s s s s s
a. anticipatory guidance. ss
b. low-risk adolescents. ss
c. physical development. ss
d. sexual development. ss
ANS: s s s s A
The HEADSS Adolescent Risk Profile is a psychosocial assessment
s s s s s s s s s s s s s s s s
screening tool which assesses home, education, activities, drugs, sex,
s s s s ss s s s s s s s s s s s s
and suicide for the purpose of identifying high-risk adolescents and
s s s s s s s s s s ss s s s s s s s s
the need for anticipatory guidance. It is used to identify high-risk,
s s s s s s s s s s s s s s ss s s s s s s
not low-risk, adolescents. Physical development is assessed with
s s s s s s s s ss s s s s ss
anthropometric data. Sexual development is assessed using physical
s s s s s s s s s s s s s s s s
examination.
ss
REF: 6 OBJ: NCLEX® Client Needs s s s s s s Category: Health Promotion and Maintenance
s s ss s s ss
2. The nurse preparing a teaching plan for a preschooler knows that,
s s s s s s s s s s s s s s s s s s s s
s s according to Piaget, the expected stage of development for a
s s ss s s s s s s s s s s s s s s
s s preschooler is s s
a. concrete operational. s s
b. formal operational. ss
c. preoperational.
d. sensorimotor.
ANS: ss ss C
The expected stage of development for a preschooler (3 to 4 years old)
s s s s s s s s s s s s s s s s s s s s s s s s
is preoperational. Concrete operational describes the thinking of a school-age
s s ss s s ss ss s s s s s s ss ss
child (7 to 11 years old). Formal operational describes the thinking of an
s s s s s s ss s s s s s s s s ss s s s s s s s s
individual after about 11 years of age. Sensorimotor describes the
s s s s s s ss s s s s s s s s s s s s
earliest pattern of thinking from birth to 2 years old.
s s s s s s s s s s s s ss s s s s s s
REF: 5 OBJ: NCLEX® Client Needs s s s s s s Category: Health Promotion and Maintenance
s s ss s s ss
3. The school nurse talking with a high school class about the difference
s s ss ss s s s s s s s s ss s s s s s s
s s between growth and development would best describe growth as
ss s s s s s s s s s s s s s s
a. processes by which early cells specialize. s s ss s s ss s s
b. psychosocial and cognitive changes. ss s s s s
c. qualitative changes associated with aging. s s s s s s ss
d. quantitative changes in size or weight. s s s s s s s s s s
ANS: ss ss D
Growth is a quantitative change in which an increase in cell number
s s s s s s s s s s s s s s s s s s s s s s
and size results in an increase in overall size or weight of the body or
s s s s s s ss s s s s s s s s s s s s s s s s ss s s ss
any of its parts. The processes by which early cells specialize are referred
s s ss s s s s s s s s ss s s s s s s s s s s s s
to as differentiation. Psychosocial and
s s s s s s s s s s
,cognitive changes are referred to as development. Qualitative changes
s s s s s s s s s s s s s s s s
associated with aging are referred to as maturation.
s s ss s s s s s s s s s s s s
, REF: 2 OBJ: NCLEX® Client Needs s s s s s s Category: Health Promotion and Maintenance s s ss s s ss
4. The most appropriate response of the nurse when a mother asks what
s s s s s s s s ss s s s s ss s s s s s s
s s the Denver II does is that it
s s ss s s s s s s s s
a. can diagnose developmental disabilities.
ss s s ss
b. identifies a need for physical therapy. ss ss s s ss ss
c. is a developmental screening tool.
ss s s ss s s
d. provides a framework for health teaching.
s s s s s s s s s s
ANS: ss ss C
The Denver II is the most commonly used measure of developmental
s s s s s s s s s s s s s s s s s s s s
status used by health care professionals; it is a screening tool. Screening
s s s s s s ss s s s s s s s s s s s s s s s s
tools do not provide a diagnosis. Diagnosis requires a thorough
s s s s s s s s s s ss s s s s s s s s
neurodevelopment history and physical examination. Developmental delay,
s s s s s s s s ss s s s s
which is suggested by screening, is a symptom, not a diagnosis. The
s s s s s s s s s s s s s s s s ss s s s s s s
need for any therapy would be identified with a comprehensive evaluation,
s s s s s s s s s s s s s s s s s s s s ss
not a screening tool. Some providers use the Denver II as a
s s s s s s s s s s s s s s s s s s s s s s s s
framework for teaching about expected development, but this is not the
s s ss s s s s s s s s s s s s s s s s s s
primary purpose of the tool.
s s s s mm s s ss
REF: 4 OBJ: NCLEX® Client Needs s s s s s s Category: Health Promotion and Maintenance s s ss s s ss
5. To plan early intervention and care for an infant with Down
ss ss ss s s s s ss s s s s s s ss
syndrome, the nurse considers knowledge of other physical
ss mm s s ss s s s s s s s s
development exemplars such as
s s mm s s s s
a. cerebral palsy. ss
b. failure to thrive. s s s s
c. fetal alcohol syndrome.ss s s
d. hydrocephaly.
ANS: ss ss D
Hydrocephaly is also a physical development exemplar. Cerebral palsy is an
s s ss s s s s ss s s s s ss ss ss
exemplar of adaptive developmental delay. Failure to thrive is an
ss ss s s s s s s s s s s s s s s s s
exemplar of social/emotional developmental delay. Fetal alcohol syndrome is
s s s s ss s s ss mm ss ss s s
an exemplar of cognitive developmental delay.
s s s s s s ss s s mm
REF: 9 OBJ: NCLEX® Client Needs Category: Health Promotion and Maintenance
s s mm s s s s ss ss ss
6. To plan early intervention and care for a child with a developmental delay, the
ss ss mm mm ss ss ss ss ss ss ss ss ss
nurse would consider knowledge of the concepts most significantly impacted by
ss mm mm ss ss ss ss ss ss ss ss
development, including
ss s s
a. culture.
b. environment.
c. functional status. ss
d. nutrition.
ANS: ss ss C
