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Giddens:ConceptsforNursingPractice, 3rdEdition
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MULTIPLE CHOICE 33
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 used
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to assess for needs related to
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a. anticipatory guidance. 33
b. low-risk adolescents. 33
c. physical development. 33
d. sexual development. 33
ANS: A 3 3
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 high-
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risk adolescents and the need for anticipatory guidance. It is used to identify high-risk, not low-
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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: NCLEXClient Needs Category: Health Promotion and Maintenance 33 33 33 33 33 33 33
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. 33
b. formal operational. N 33
c. preoperational.
d. sensorimotor.
ANS: C 3 3
The expected stage of development for a preschooler (3–4 years old) is pre-operational. Concrete
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operational describes the thinking of a school-age child (7–11 years old). Formal operational
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describes the thinking of an individual after about 11 years of age. Sensorimotor describes the
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earliest pattern of thinking from birth to 2 years old.
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OBJ: NCLEXClient Needs Category: Health Promotion and Maintenance 33 33 33 33 33 33 33
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. 33 33 33 33 33
b. psychosocial and cognitive changes. 33 33 33
c. qualitative changes associated with aging. 33 33 33 33
d. quantitativechangesin sizeor weight. 33 33 33 33 33
33 ANS: D 3 3
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, Growth is a quantitative change in which an increase in cell number and size results in an increase
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in overall size or weight of the body or any of its parts. The processes by which early cells
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specialize are referred to as differentiation. Psychosocial and cognitive changes are referred to as
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development. Qualitative changes associated with aging are referred to as maturation.
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OBJ: NCLEXClient Needs Category: Health Promotion and Maintenance 33 33 33 33 33 33 33
4. The most appropriate response of the nurse when a mother asks what the Denver II does is that it
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a. can diagnose developmental disabilities. 33 33 33
b. identifies a need for physical therapy. 33 33 33 33 33
c. is a developmental screening tool.
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d. provides a framework for health teaching. 33 33 33 33 33
ANS: C 3 3
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 requires
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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 for 33 33 33 33 33 33 33 33 33 33 33 33 33 33 33
any therapy would be identified with a comprehensive evaluation, not a screening tool. Some
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providers use the Denver II as a framework for teaching about expected development, but this is
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not the primary purpose of the tool.
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OBJ: NCLEXClient Needs Category: Health Promotion and Maintenance 33 33 33 33 33 33 33
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. 33
b. autism.
c. attention-deficit/hyperactivitydisorder (ADHD). 33 33
d. failureto thrive. 33 33
ANS: D 3 3
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 delay.
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ADHD is an exemplar of a cognitive disorder.
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OBJ: NCLEXClient Needs Category: Health Promotion and Maintenance 33 33 33 33 33 33 33
6. To plan early intervention and care for a child with a developmental delay, the nurse would
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consider knowledgeof theconcepts most significantly impacted by development, including
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a. culture.
b. environment.
c. functional status. 33
d. nutrition.
ANS: C
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, Function is one of the concepts most significantly impacted by development. Others include
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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 that is
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considered to significantly affect development; the difference is the concepts that affect
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development are those that represent major influencing factors (causes); hence determination of
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development would be the focus of preventive interventions. Environment is considered to
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significantly affect development. Nutrition is considered to significantly affect development.
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OBJ: NCLEXClient Needs Category: Health Promotion and Maintenance 33 33 33 33 33 33 33
7. A mother complains to the nurse at the pediatric clinic that her 4-year-old child always talks to her
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toys and makes up stories. The mother wants her child to have a psychological evaluation. The
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nurse’s best initial response is to
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a. refer the child to a psychologist immediately. 33 33 33 33 33 33
b. explain that playing make believe is normal at this age. 33 33 33 33 33 33 33 33 33
c. completea developmental screening using a validated tool. 33 33 33 33 33 33 33
d. separate the child from the mother to get more information. 33 33 33 33 33 33 33 33 33
ANS: B 3 3
By the end of the fourth year, it is expected that a child will engage in fantasy, so this is normal at
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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 from
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the mother is not necessary at this time.
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OBJ: NCLEXClient NeedsNCategory: Health Promotion and Maintenance 3 33 33 33 33 33
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, adolescents
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a. haveseparation anxiety. 33 33
b. rebel against rules. 33 33
c. regress becauseof stress. 33 33 33
d. want to know everything. 33 33 33
ANS: C 3 3
Regression to an earlier stage of development is a common response to stress. Separation anxiety 33 33 33 33 33 33 33 33 33 33 33 33 33 33
is most common in infants and toddlers. Rebellion against hospital rules is usually not an issue if
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the adolescent understands the rules and would not create childlike behaviors. An adolescent may
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want to “know everything” with their logical thinking and deductive reasoning, but that would
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not explain why they would act like a child.
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OBJ: NCLEXClient Needs Category: Health Promotion and Maintenance 33 33 33 33 33 33 33
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