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Giddens:ConceptsforNursingPractice,3rdEdition
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MULTIPLE CHOICE v
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 to
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assess for needs related to
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a. anticipatoryguidance. v
b. low-risk adolescents. v
c. physicaldevelopment. v
d. sexual development. v
ANS: A v
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 isused to identifyhigh-risk, not low-
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risk, adolescents. Physical development is assessed with anthropometric data.
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Sexual development isassessed using physical examination.
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OBJ: NCLEXClient NeedsCategory:HealthPromotion andMaintenance v v v v v v v
2. The nursepreparing ateaching plan for a preschoolerknowsthat, according to Piaget, the
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expected stage of development for a preschooler is
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a. concreteoperational. v
b. formaloperational. N v
c. preoperational.
d. sensorimotor.
ANS: C v
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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describesthe thinking of an individualafter 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 NeedsCategory:Health Promotion andMaintenance v v v v v v v
3. Theschool nurse talking witha high school classabout the differencebetween growth and
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development would best describe growth as
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a. processes bywhich early cells specialize. v v v v v
b. psychosocial and cognitivechanges. v v v
c. qualitative changes associatedwith aging. v v v v
d. quantitativechangesinsizeorweight. v v v v v
v ANS: D v
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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 specialize
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are referred to as differentiation. Psychosocial and cognitive changes arereferredto as
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development.Qualitative changes associated with aging arereferred toas maturation.
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OBJ: NCLEXClient NeedsCategory:HealthPromotion andMaintenance v v v v v v v
4. The mostappropriate response of the nurse when a mother askswhat the Denver II doesis that it
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a. can diagnosedevelopmental disabilities.
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b. identifies aneed for physical therapy. v v v v v
c. isa developmental screening tool.
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d. providesa framework for health teaching. v v v v v
ANS: C v
The Denver II is the most commonly used measure of developmental status used by healthcare
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professionals;it is a screeningtool. Screening tools do not provide adiagnosis. Diagnosis requires a
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thorough neurodevelopment history and physical examination.
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Developmental delay, which issuggested by screening, isa symptom, not a diagnosis. The need for v v v v v v v v v v v v v v v
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 not
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the primary purpose of the tool.
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OBJ: NCLEXClient NeedsCategory: HealthPromotion andMaintenance v v v v v v v
5. Toplanearlyinterventiona n Nd careforaninfantwithDownsyndrome,thenurseconsiders
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knowledge of other physical development exemplars such as
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a. cerebralpalsy. v
b. autism.
c. attention-deficit/hyperactivitydisorder(ADHD). v v
d. failureto thrive. v v
ANS: D v
Failuretothriveis also a physicaldevelopment exemplar. Cerebralpalsy is anexemplar 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 NeedsCategory:HealthPromotion andMaintenance v v v v v v v
6. To plan early intervention and carefor a child with adevelopmental delay, the nurse would
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considerknowledgeof theconcepts most significantlyimpactedby development,including
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a. culture.
b. environment.
c. functional status. v
d. nutrition.
vANS: C v
, Function isone of theconceptsmost 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 NeedsCategory:HealthPromotion andMaintenance v v v v v v v
7. A mother complains to the nurse at the pediatric clinic thather 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.v v v v v v
b. explain that playing makebelieveis normal at this age. v v v v v v v v v
c. completea developmental screening using a validated tool. v v v v v v v
d. separatethechild from the mother toget moreinformation. v v v v v v v v v
ANS: B v
By the end of the fourth year, it is expected that a child will engage in fantasy, so this is normal at this
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age. A referral to a psychologist would be premature based only on the complaintof the mother.
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Completing adevelopmental screening would be very appropriate but not the initial response. The
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nurse would certainly want to get more information, but separating the child from the mother is not
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necessary at this time.
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OBJ: NCLEXClientNeedsNCategory: HealthPromotionandMaintenance v v v v v v
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. v v
b. rebelagainst rules. v v
c. regress becauseof stress. v v v
d. want to know everything. v v v
ANS: C v
Regression to an earlier stage of development is a common response to stress. Separation anxiety is
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most common in infants and toddlers. Rebellion against hospital rules is usually notan issue if the
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adolescent understands the rulesand 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 not
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explain why they would act like a child.
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OBJ: NCLEXClient NeedsCategory:HealthPromotion andMaintenance v v v v v v v
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