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Giddens: Concepts forNursing Practice,
b a ba b a b a 3rdEdition
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MULTIPLECHOICE
1. The nurse manager of a pediatric clinic could confirm that the new nurse recognized the
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purposeofthe HEADSS AdolescentRiskProfile whenthenew nurserespondsthatit is used
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toassessforneedsrelatedto
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a. anticipatoryguidance.
b. low-riskadolescents.
c. physicaldevelopment. m/
d. sexualdevelopment.
ANS: A
TheHEADSSAdolescentRiskProfileisapsychosocialassessmentscreeningtoolwhich
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assesseshome,education,activities,drugs,sex,andsuicideforthepurposeofidentifying high-
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riskadolescentsandtheneedforanticipatoryguidance.Itisusedtoidentifyhigh-risk,not low-
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risk,adolescents.Physicaldevelopmentisassessedwithanthropometricdata.
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Sexualdevelopmentisassessedusing physicalexamination. m
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OBJ: NCLEXClientNeedsCategory:HealthPromotionandMaintenance
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2. Thenursepreparingateachingplanforapreschoolerknowsthat,accordingtoPiaget,the
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expectedstageofdevelopmentforapreschooleris
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a. concreteoperational. /
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b. formaloperational. N /
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c. preoperational.
d. sensorimotor.
ANS: C
Theexpected stage ofdevelopment forapreschooler(3–4yearsold)ispre-operational.Concrete
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operationaldescribesthethinkingofaschool-agechild(7–11yearsold).Formaloperational
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describesthethinkingofanindividualafterabout11yearsofage.Sensorimotor
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describestheearliest patternofthinkingfrombirthto2yearsold.
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OBJ: NCLEXClientNeedsCategory:Health PromotionandMaintenance
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3. Theschoolnursetalking withahighschoolclassaboutthedifferencebetweengrowthand
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development would bestdescribegrowthas
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a. processesbywhichearlycellsspecialize. m
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b. psychosocialandcognitivechanges. m
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c. qualitativechangesassociatedwithaging. m
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d. quantitativechangesinsizeorweight /
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. ANS: D ba
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, Growthisa quantitativechangeinwhichanincreaseincellnumberandsizeresultsinan
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bincreaseinoverallsizeorweightofthebodyoranyof itsparts. The processesbywhich early
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bcellsspecializeare referred toasdifferentiation.Psychosocialandcognitivechangesare
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referred toasdevelopment.Qualitativechangesassociatedwithagingarereferredtoas
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maturation.
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OBJ: NCLEXClientNeedsCategory:HealthPromotionandMaintenance /
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4. Themostappropriateresponseofthenursewhen amotheraskswhattheDenver IIdoesis thatit
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a. can diagnosedevelopmentaldisabilities. m/ ba
b. identifiesaneedforphysicaltherapy. m
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c. isadevelopmentalscreening tool.
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d. providesaframeworkforhealthteaching. /
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ANS: C
TheDenverIIis themostcommonlyusedmeasureofdevelopmentalstatususedbyhealthcare
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professionals;itisascreeningtool.Screeningtoolsdonotprovideadiagnosis.Diagnosisrequires
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athoroughneurodevelopmenthistoryandphysicalexamination.
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Developmentaldelay,whichissuggestedbyscreening,isa symptom,nota diagnosis.The need m/ m/ m
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foranytherapywouldbeidentifiedwithacomprehensiveevaluation, notascreening tool. Some
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providers use the Denver IIasaframeworkforteachingaboutexpecteddevelopment, butthis
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isnottheprimarypurposeofthetool.
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OBJ: b a b a NCLEXClientNeedsCategory:HealthPromotionandMaintenance/
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5. Toplanearlyinterventiona nNd careforaninfantwithDownsyndrome,the /
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nurse considers knowledgeofotherphysicaldevelopmentexemplarssuchas
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a. cerebralpalsy. /
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b. autism.
c. attention-deficit/hyperactivitydisorder (ADHD). ba b a
d. failuretothrive. /
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ANS: D b a b a
Failuretothriveisalsoaphysicaldevelopmentexemplar.Cerebralpalsyisanexemplarof /
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motor/developmentaldelay.Autismisanexemplarofsocial/emotionaldevelopmentaldelay.
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ADHDisanexemplarofacognitivedisorder.
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OBJ: b a b a NCLEXClientNeedsCategory:HealthPromotionandMaintenance/
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6. Toplan earlyinterventionand careforachild withadevelopmentaldelay,thenursewould
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considerknowledgeoftheconceptsmostsignificantlyimpactedbydevelopment,including
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a. culture.
b. environment.
c. functionalstatus. /
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d. nutrition.
ANS: C
, Functionisoneoftheconceptsmostsignificantlyimpactedbydevelopment.Othersinclude
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sensory-perceptual,cognition,mobility,reproduction,andsexuality.Knowledgeofthese
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conceptscanhelpthenurseanticipateareasthatneedtobeaddressed.Cultureis aconcept that is
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consideredtosignificantlyaffectdevelopment;thedifferenceistheconceptsthataffect
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developmentarethosethatrepresentmajorinfluencingfactors(causes);hencedetermination
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ofdevelopmentwouldbethefocusofpreventiveinterventions.
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Environmentisconsideredtosignificantlyaffectdevelopment.Nutritionisconsideredto ba
significantlyaffectdevelopment.
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OBJ: NCLEXClientNeedsCategory:HealthPromotionandMaintenance /
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7. Amothercomplainstothenurseatthepediatric clinicthather4-year-old childalwaystalks toher m
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toysandmakesupstories. Themotherwantsherchildtohaveapsychologicalevaluation. The
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nurse‘sbestinitialresponseisto
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a. referthechildtoapsychologistimmediately. ba
b. explainthatplayingmakebelieveisnormalatthisage. m
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c. completeadevelopmentalscreeningusingavalidatedtool. /
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d. separatethechildfromthemother toget moreinformation. /
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ANS: B
Bytheend ofthefourthyear,itisexpectedthatachildwillengageinfantasy,sothisisnormalat
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bthisage.A referral toapsychologist wouldbepremature basedonlyonthecomplaintofthe
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bmother.Completingadevelopmentalscreeningwouldbeveryappropriatebutnottheinitial
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response.Thenursewould certainlywanttoget more information,butseparatingthechild
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from themotherisnotnecessaryatthistime.
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OBJ: NCLEXClientNeedsNCategory:HealthPromotionandMaintenance m
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8. A17-year-oldgirlishospitalizedforappendicitis,and hermotherasksthenursewhysheis so m/ m/ m/ m/ ba m/ba
needyand actinglike achild.Thebestresponseofthenurseisthatinthehospital,adolescents
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a. haveseparationanxiety. /
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b. rebelagainstrules. /
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c. regressbecauseofstress. /
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d. wanttoknoweverything.
ANS: C
Regressiontoanearlierstageofdevelopmentisacommonresponsetostress.Separationanxiety ba ba
bismostcommonininfantsandtoddlers.Rebellionagainst hospital rulesisusually notanissueif
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theadolescentunderstandstherulesandwouldnotcreatechildlikebehaviors.Anadolescentmay
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want to―knoweverything‖with their logical thinkingand deductive reasoning,butthatwould
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not explainwhytheywould actlikeachild.
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OBJ: NCLEXClientNeedsCategory:HealthPromotionandMaintenance /
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