,Advanced Practice Nursing: Doing What Has to Be Done-Radicals, Renegades,
andRebels
1. The nurse manager of a pediatric clinic could confirm that the new nurse
recognized the purposeof 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.
ANS: A
The HEADSS Adolescent Risk Profile is a psychosocial assessment screening tool
which assesseshome, 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.
REF: 6 OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance
2. The nurse preparing a teaching plan for a preschooler knows that, according
to Piaget, theexpected stage of development for a preschooler is
,a. concrete operational.
b. formal operational.
c. preoperational.
d. sensorimotor.
ANS: C
The expected stage of development for a preschooler (3 to 4 years old) is
preoperational. Concreteoperational describes the thinking of a school-age child (7
to 11 years old). Formal operationaldescribes the thinking of an individual after
about 11 years of age. Sensorimotor describes theearliest pattern of thinking from
birth to 2 years old.
REF: 5 OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance
3. The school nurse talking with a high school class about the difference
between growth anddevelopment 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.
ANS: D
Growth is a quantitative change in which an increase in cell number and size results
in an increasein overall size or weight of the body or any of its parts. The processes
, by lwhich learly lcells lspecialize lare lreferred lto lasdifferentiation. lPsychosocial land
cognitive lchanges lare lreferred lto las ldevelopment. lQualitative lchanges lassociated
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with laging lare lreferred lto las lmaturation.
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REF: l2 lOBJ: lNCLEX lClient lNeeds lCategory: lHealth lPromotion land lMaintenance
4. The lmost lappropriate lresponse lof lthe lnurse lwhen la lmother lasks lwhat lthe lDenver
lII ldoes lis lthat lit
a. can ldiagnose ldevelopmental ldisabilities.
b. identifies la lneed lfor lphysical ltherapy.
c. is la ldevelopmental lscreening ltool.
d. provides la lframework lfor lhealth lteaching.
ANS: lC
The lDenver lII lis lthe lmost lcommonly lused lmeasure lof ldevelopmental lstatus lused
by lhealth lcare lprofessionals; lit lis la lscreening ltool. lScreening ltools ldo lnot lprovide
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a ldiagnosis. lDiagnosis lrequires lathorough lneurodevelopment lhistory land lphysical
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examination. lDevelopmental ldelay, lwhich lis lsuggested lby lscreening, lis la
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symptom, lnot la ldiagnosis. lThe lneed lfor lany ltherapy lwould lbe lidentified lwith la
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comprehensive levaluation, lnot la lscreening ltool. lSome lproviders luse lthe lDenver lII
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as la lframework lfor lteaching labout lexpected ldevelopment, lbut lthis lis lnot lthe
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primary lpurpose lof lthe ltool.
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