PRACTICE
4TH EDITION
• AUTHOR(S)JEAN FORET
GIDDENS
TEST BANK
Question 1
Reference
Ch. 1 — Development — Attributes & Theoretical Links
NCLEX-Level Question Stem
A nurse is conducting a well-child visit for a 15-month-old
toddler. The parent expresses frustration, stating, "He says 'No!'
to everything and has a tantrum when I try to put him in his car
seat." Based on the child's developmental stage, how should
the nurse respond?
,Options
A. "This is a sign of willful misbehavior. You should implement a
consistent time-out procedure."
B. "This is expected as he learns to exert his independence.
Offer limited, simple choices when possible."
C. "He may be experiencing anxiety from separation. Provide
extra comfort and reassurance during transitions."
D. "This behavior suggests a developmental delay in social skills.
We should refer him for a formal evaluation."
Correct Answer
B
Rationales
Correct Option (B): This behavior is characteristic of Erikson's
stage of Autonomy vs. Shame and Doubt. Toddlers are
developing a sense of personal control and independence.
Guiding the parent to offer limited, acceptable choices (e.g.,
"Do you want to put on your red shoes or blue shoes?")
supports this developmental task while maintaining necessary
limits, promoting healthy development.
Incorrect Option (A): Time-out is not developmentally
appropriate for a 15-month-old, who cannot yet link actions
with prolonged consequences. This approach could foster
shame and doubt.
Incorrect Option (C): Separation anxiety peaks around 8-18
months but typically manifests as distress when separated from
a primary caregiver, not as negativism during routine tasks like
,car seat placement.
Incorrect Option (D): Asserting independence through "no" and
tantrums is a normal, expected milestone for a toddler, not an
indicator of a social skills delay.
Teaching Point
In Erikson's theory, the toddler's task is autonomy. Nursing care
should support safe independence through simple choices.
Citation
Giddens, J. F. (2025). Concepts for Nursing Practice (4th ed.).
Chapter 1.
Question 2
Reference
Ch. 1 — Development — Clinical Exemplars (Adolescent)
NCLEX-Level Question Stem
A 16-year-old client is admitted to the emergency department
following a motor vehicle crash. Their parents are in the waiting
room. When the nurse enters to start an IV, the client is alert
and says, "Please don't tell my parents I had a beer at the party
before driving. I'll never do it again." What is the nurse's priority
action?
Options
A. Respect the adolescent's confidentiality and document the
statement only in the private nursing notes.
B. Inform the client that, because they are a minor, the
, information must be shared with the parents and the police.
C. Explain to the client that the healthcare team needs this
information for safe treatment and it will be shared with the
physician.
D. Acknowledge the client's concern and assess their immediate
safety and neurologic status before deciding on next steps.
Correct Answer
C
Rationales
Correct Option (C): The nurse's primary obligation is to safe,
effective treatment. Information about substance use is directly
relevant to clinical assessment (e.g., altered mental status,
interactions with medications). The nurse should be honest that
this information is part of the medical record and will be shared
with the treating team. While considering developmental needs
for privacy, safety and accurate treatment come first.
Incorrect Option (A): Withholding information about substance
use relevant to the cause of the injury and current treatment
from the medical team violates principles of safe care and
accurate documentation.
Incorrect Option (B): While information is shared with the care
team, automatically involving police is not the nurse's priority
action and may not be required, depending on state laws. The
immediate focus is on clinical treatment.
Incorrect Option (D): While safety and neuro checks are always
important, the statement about alcohol is a critical assessment