,Concept01:Development
i. i.
Giddens:ConceptsforNursingPractice,3rdEdition
i. i. i. i. i. i.
MULTIPLECHOICE i.
1. The nurse manager of a pediatric clinic could confirm that the new nurse recognized the
i. i.i i.i i.i i.i i.i i.i i.i i.i i.i i.i i.i i.i i.i
purpose of the HEADSS Adolescent Risk Profile when the new nurse responds that it is used
i.i i.i i.i i.i i.i i.i i.i i.i i.i i.i i.i i.i i.i i.i i.i i.i
to assess for needs related to
i.i i .i i .i i.i i .i i.i
a. anticipatoryguidance. i.
b. low-risk adolescents. i.i
c. physicaldevelopment. i.i
d. sexualdevelopment. i.
ANS: A i . i
The HEADSS Adolescent Risk Profile is a psychosocial assessment screening tool which
i.i i.i i.i i. i i.i i. i i. i i.i i.i i.i i .i
assesses home, education, activities, drugs, sex, and suicide for the purpose of identifying high-
i.i i .i i. i i.i i.i i. i i.i i.i i.i i. i i.i i.i i. i i.i
riskadolescentsand the needfor anticipatory guidance. Itisused to identifyhigh-risk, not low-
i.i i.i i.i i.i i.i i.i i.i i.i i.i i.i i.i i.i i.i i .i i .i
risk, adolescents. Physical development is assessed with anthropometric data.
i.i i.i i.i i.i i.i i .i i. i i.i
Sexualdevelopment is assessed using physical examination.
i.i i.i i.i i.i i.i i.i
OBJ: NCLEXClientNeedsCategory:HealthPromotionand Maintenance i. i.i i. i.i i. i. i.
2. Thenursepreparing ateachingplan fora preschoolerknows that, according to Piaget,the
i. i.i i.i i.i i.i i.i i. i.i i. i.i i.i i.i i.i i.i
expected stage of development for a preschooler is
i.i i.i i.i i.i i.i i. i i. i i.i
a. concreteoperational. i.
b. formaloperational. N i.
c. preoperational.
d. sensorimotor.
ANS: C i . i
The expected stage of development for a preschooler (3–4 years old) is pre-operational. Concrete
i.i i.i i.i i. i i.i i.i i.i i.i i.i i.i i.i i. i i.i
operational describes the thinking of a school-age child (7–11 years old). Formal operational
i.i i.i i.i i.i i. i i. i i. i i.i i.i i. i i. i i.i i.i
describesthe thinkingof an individualafter about11 years of age. Sensorimotor describes the
i.i i.i i.i i.i i.i i.i i.i i.i i.i i.i i.i i.i i.i i. i i.i
earliest pattern of thinking from birth to 2 years old.
i.i i.i i.i i. i i.i i. i i.i i.i i. i i.i
OBJ: NCLEXClientNeedsCategory:Health Promotionand Maintenance i. i.i i. i.i i.i i. i.
3. Theschoolnursetalking witha high schoolclass aboutthe differencebetweengrowth and
i. i.i i.i i.i i.i i.i i.i i.i i.i i.i i.i i. i.i i.i
development would best describe growth as
i.i i.i i.i i.i i. i i. i
a. processesbywhichearly cellsspecialize. i. i. i. i.i i.i
b. psychosocialand cognitivechanges. i.i i.i i.
c. qualitativechanges associatedwith aging. i.i i.i i.i i.i
d. quantitativechangesinsizeorweight. i. i. i. i. i.
i.i ANS: D i . i
WWW.NURSYLAB.COM
, Growth is a quantitative change in which an increase in cell number and size results in an increase
i. i i. i i. i i.i i.i i.i i.i i.i i.i i.i i.i i. i i.i i.i i .i i. i i. i
in overall size or weight of the body or any of its parts. The processes by which early cells
i.i i .i i.i i.i i. i i.i i.i i .i i.i i. i i. i i. i i.i i. i i.i i. i i .i i. i i.i
specialize are referred to as differentiation. Psychosocial and cognitive changes arereferredto as
i.i i.i i.i i.i i.i i. i i.i i.i i.i i.i i. i i. i.i i.i
development.Qualitativechangesassociated withaging arereferredto as maturation.
i.i i.i i.i i.i i.i i.i i.i i. i. i.i i. i
OBJ: NCLEXClientNeedsCategory:HealthPromotionand Maintenance i. i.i i. i.i i. i. i.
4. Themost appropriate response of thenurse when a mother asks what theDenver IIdoes is that it
i. i.i i.i i.i i.i i.i i.i i.i i.i i.i i.i i.i i.i i.i i. i.i i. i i.i
a. can diagnosedevelopmental disabilities. i.i i.i i. i
b. identifiesaneed for physical therapy. i.i i. i.i i.i i.i
c. isa developmental screening tool. i.i i.i i.i i.i
d. providesaframework for health teaching. i.i i. i.i i. i i.i
ANS: C i . i
The Denver II is the most commonly used measure of developmental status used by healthcare
i.i i.i i. i i .i i. i i.i i.i i. i i.i i .i i.i i. i i. i i .i
professionals; itis a screeningtool. Screeningtools do notprovideadiagnosis. Diagnosis requires a
i. i.i i.i i.i i.i i.i i.i i.i i.i i.i i.i i.i i.i i .i i.i i.i
thorough neurodevelopment history and physical examination.
i.i i .i i.i i. i i. i i.i
Developmental delay, which is suggested by screening,is a symptom, nota diagnosis. The need for i.i i.i i.i i.i i.i i.i i.i i.i i.i i.i i.i i.i i.i i.i i.i
any therapy would be identifiedwith a comprehensive evaluation, not a screening tool. Some
i.i i.i i.i i.i i.i i.i i.i i.i i.i i.i i.i i.i i.i i.i
providers use the Denver II as a framework for teaching about expected development, but this is
i.i i .i i.i i. i i. i i. i i .i i .i i.i i.i i.i i.i i.i i.i i.i i .i
not the primary purpose of the tool.
i.i i .i i. i i.i i .i i.i i. i
OBJ: NCLEXClientNeedsCategory: HealthPromotionand Maintenance i. i. i. i.i i. i. i.
5. Toplanearlyinterventiona n Nd careforaninfantwithDownsyndrome,thenurseconsiders
i. i. i. i. i. i. i. i. i. i. i. i. i. i.
knowledge of other physical development exemplars such as
i.i i. i i. i i.i i.i i.i i.i i.i
a. cerebralpalsy. i.
b. autism.
c. attention-deficit/hyperactivitydisorder(ADHD). i. i.
d. failureto thrive. i. i.i
ANS: D i . i
Failuretothriveis also a physicaldevelopmentexemplar.Cerebralpalsy is an exemplarof
i. i.i i. i.i i.i i.i i.i i.i i. i.i i.i i.i i.i i.i
motor/developmental delay. Autism is an exemplar of social/emotional developmental delay.
i.i i.i i.i i. i i .i i. i i.i i.i i.i i.i
ADHD is an exemplar of a cognitive disorder.
i.i i. i i .i i. i i.i i. i i.i i.i
OBJ: NCLEXClientNeedsCategory:HealthPromotionand Maintenance i. i.i i. i.i i. i. i.
6. To plan early intervention and carefor a child with a developmental delay, the nurse would
i.i i.i i.i i.i i.i i.i i.i i.i i.i i.i i.i i.i i.i i.i i.i
considerknowledgeoftheconceptsmost significantlyimpactedby development,including
i.i i. i. i. i. i.i i.i i. i. i.i i.i
a. culture.
b. environment.
c. functionalstatus. i.
d. nutrition.
i.i ANS: C i . i
, Functionisoneof the conceptsmost significantlyimpactedby development.Others include i.i i.i i.i i.i i.i i.i i.i i.i i.i i.i i.i i.i
sensory-perceptual, cognition, mobility, reproduction, and sexuality. Knowledge of these
i.i i.i i.i i.i i.i i.i i.i i.i i.i
concepts can help the nurse anticipate areas that need to be addressed. Culture is a concept that is
i.i i.i i. i i.i i .i i.i i.i i.i i.i i.i i .i i .i i. i i.i i.i i.i i.i i.i
considered to significantly affect development; the difference is the concepts that affect
i.i i.i i.i i.i i.i i.i i.i i.i i. i i.i i.i i. i
development are those that represent major influencing factors (causes); hence determination of
i.i i.i i.i i. i i.i i.i i.i i.i i.i i.i i.i i.i
development would be the focus of preventive interventions. Environment is considered to
i.i i.i i.i i.i i .i i.i i.i i.i i.i i.i i.i i. i
significantly affect development. Nutrition is considered to significantly affect development.
i.i i.i i.i i.i i.i i. i i.i i. i i.i i.i
OBJ: NCLEXClientNeedsCategory:HealthPromotionand Maintenance i. i.i i. i.i i. i. i.
7. A mothercomplains to the nurseat the pediatric clinicthat her4-year-old child always talks to her
i.i i. i.i i.i i.i i.i i.i i.i i.i i.i i.i i. i.i i.i i.i i.i i.i
toys and makes up stories. The mother wants her child to have a psychological evaluation. The
i.i i.i i.i i. i i .i i .i i. i i.i i .i i.i i.i i .i i. i i. i i.i i.i
nurse’s best initial response is to
i.i i. i i. i i.i i.i i.i
a. referthechild to a psychologist immediately. i.i i.i i.i i.i i.i i.i
b. explain thatplaying makebelieveis normal at this age. i.i i.i i.i i. i.i i.i i.i i.i i.i
c. completeadevelopmental screening using a validated tool. i. i. i.i i.i i.i i.i i.i
d. separatethe child from the mother toget moreinformation. i. i.i i.i i.i i.i i.i i. i.i i.
ANS: B i . i
By the end of the fourth year, it is expected that a child will engage in fantasy, so this is normal at this
i.i i. i i. i i .i i. i i. i i.i i. i i .i i.i i.i i.i i. i i.i i. i i.i i .i i. i i. i i .i i.i i.i
age. A referral to a psychologist would be premature based only on the complaintof themother.
i.i i. i i.i i.i i. i i. i i.i i. i i. i i.i i.i i.i i. i i.i i. i.i i.
Completingadevelopmental screeningwouldbe very appropriate but not the initial response. The
i.i i.i i.i i.i i.i i.i i.i i. i i.i i.i i .i i. i i.i i.i
nurse would certainly want to get more information, but separating the child from the mother is not
i.i i.i i. i i.i i. i i. i i.i i. i i.i i.i i.i i.i i. i i.i i .i i.i i.i
necessary at this time.
i.i i. i i.i i .i
OBJ: NCLEXClientNeedsNCategory: HealthPromotionand Maintenance i. i. i.i i. i. i.i
8. A 17-year-old girl is hospitalizedforappendicitis,and her mother asks the nursewhy sheis so
i.i i.i i.i i.i i.i i.i i.i i.i i.i i.i i.i i.i i.i i.i i.i i. i
needy and acting like a child. The best response of the nurse is that in the hospital, adolescents
i.i i. i i.i i.i i. i i. i i.i i.i i.i i.i i. i i.i i.i i. i i.i i. i i.i i.i
a. haveseparation anxiety. i. i.i
b. rebelagainst rules. i. i.i
c. regressbecauseofstress. i. i. i.
d. want to know everything. i.i i.i i.i
ANS: C i . i
Regression to an earlier stage of development is a common response to stress. Separation anxiety i.i i. i i. i i.i i.i i .i i.i i.i i.i i.i i. i i. i i.i i.i
is most common in infants and toddlers. Rebellion against hospital rules is usually not an issue if
i.i i.i i.i i. i i.i i .i i .i i. i i.i i.i i.i i.i i. i i.i i.i i.i i.i
the adolescentunderstandsthe rulesand wouldnot createchildlikebehaviors. An adolescent may
i. i.i i.i i.i i.i i.i i.i i.i i.i i. i. i.i i. i i.i
want to “know everything” with their logical thinking and deductive reasoning, but that would
i.i i .i i. i i .i i.i i. i i.i i.i i.i i.i i.i i.i i.i i.i
not explain why they would act like a child.
i.i i .i i.i i.i i .i i.i i. i i.i i. i
OBJ: NCLEXClientNeedsCategory:HealthPromotionand Maintenance i. i.i i. i.i i. i. i.
WWW.NURSYLAB.COM
i. i.
Giddens:ConceptsforNursingPractice,3rdEdition
i. i. i. i. i. i.
MULTIPLECHOICE i.
1. The nurse manager of a pediatric clinic could confirm that the new nurse recognized the
i. i.i i.i i.i i.i i.i i.i i.i i.i i.i i.i i.i i.i i.i
purpose of the HEADSS Adolescent Risk Profile when the new nurse responds that it is used
i.i i.i i.i i.i i.i i.i i.i i.i i.i i.i i.i i.i i.i i.i i.i i.i
to assess for needs related to
i.i i .i i .i i.i i .i i.i
a. anticipatoryguidance. i.
b. low-risk adolescents. i.i
c. physicaldevelopment. i.i
d. sexualdevelopment. i.
ANS: A i . i
The HEADSS Adolescent Risk Profile is a psychosocial assessment screening tool which
i.i i.i i.i i. i i.i i. i i. i i.i i.i i.i i .i
assesses home, education, activities, drugs, sex, and suicide for the purpose of identifying high-
i.i i .i i. i i.i i.i i. i i.i i.i i.i i. i i.i i.i i. i i.i
riskadolescentsand the needfor anticipatory guidance. Itisused to identifyhigh-risk, not low-
i.i i.i i.i i.i i.i i.i i.i i.i i.i i.i i.i i.i i.i i .i i .i
risk, adolescents. Physical development is assessed with anthropometric data.
i.i i.i i.i i.i i.i i .i i. i i.i
Sexualdevelopment is assessed using physical examination.
i.i i.i i.i i.i i.i i.i
OBJ: NCLEXClientNeedsCategory:HealthPromotionand Maintenance i. i.i i. i.i i. i. i.
2. Thenursepreparing ateachingplan fora preschoolerknows that, according to Piaget,the
i. i.i i.i i.i i.i i.i i. i.i i. i.i i.i i.i i.i i.i
expected stage of development for a preschooler is
i.i i.i i.i i.i i.i i. i i. i i.i
a. concreteoperational. i.
b. formaloperational. N i.
c. preoperational.
d. sensorimotor.
ANS: C i . i
The expected stage of development for a preschooler (3–4 years old) is pre-operational. Concrete
i.i i.i i.i i. i i.i i.i i.i i.i i.i i.i i.i i. i i.i
operational describes the thinking of a school-age child (7–11 years old). Formal operational
i.i i.i i.i i.i i. i i. i i. i i.i i.i i. i i. i i.i i.i
describesthe thinkingof an individualafter about11 years of age. Sensorimotor describes the
i.i i.i i.i i.i i.i i.i i.i i.i i.i i.i i.i i.i i.i i. i i.i
earliest pattern of thinking from birth to 2 years old.
i.i i.i i.i i. i i.i i. i i.i i.i i. i i.i
OBJ: NCLEXClientNeedsCategory:Health Promotionand Maintenance i. i.i i. i.i i.i i. i.
3. Theschoolnursetalking witha high schoolclass aboutthe differencebetweengrowth and
i. i.i i.i i.i i.i i.i i.i i.i i.i i.i i.i i. i.i i.i
development would best describe growth as
i.i i.i i.i i.i i. i i. i
a. processesbywhichearly cellsspecialize. i. i. i. i.i i.i
b. psychosocialand cognitivechanges. i.i i.i i.
c. qualitativechanges associatedwith aging. i.i i.i i.i i.i
d. quantitativechangesinsizeorweight. i. i. i. i. i.
i.i ANS: D i . i
WWW.NURSYLAB.COM
, Growth is a quantitative change in which an increase in cell number and size results in an increase
i. i i. i i. i i.i i.i i.i i.i i.i i.i i.i i.i i. i i.i i.i i .i i. i i. i
in overall size or weight of the body or any of its parts. The processes by which early cells
i.i i .i i.i i.i i. i i.i i.i i .i i.i i. i i. i i. i i.i i. i i.i i. i i .i i. i i.i
specialize are referred to as differentiation. Psychosocial and cognitive changes arereferredto as
i.i i.i i.i i.i i.i i. i i.i i.i i.i i.i i. i i. i.i i.i
development.Qualitativechangesassociated withaging arereferredto as maturation.
i.i i.i i.i i.i i.i i.i i.i i. i. i.i i. i
OBJ: NCLEXClientNeedsCategory:HealthPromotionand Maintenance i. i.i i. i.i i. i. i.
4. Themost appropriate response of thenurse when a mother asks what theDenver IIdoes is that it
i. i.i i.i i.i i.i i.i i.i i.i i.i i.i i.i i.i i.i i.i i. i.i i. i i.i
a. can diagnosedevelopmental disabilities. i.i i.i i. i
b. identifiesaneed for physical therapy. i.i i. i.i i.i i.i
c. isa developmental screening tool. i.i i.i i.i i.i
d. providesaframework for health teaching. i.i i. i.i i. i i.i
ANS: C i . i
The Denver II is the most commonly used measure of developmental status used by healthcare
i.i i.i i. i i .i i. i i.i i.i i. i i.i i .i i.i i. i i. i i .i
professionals; itis a screeningtool. Screeningtools do notprovideadiagnosis. Diagnosis requires a
i. i.i i.i i.i i.i i.i i.i i.i i.i i.i i.i i.i i.i i .i i.i i.i
thorough neurodevelopment history and physical examination.
i.i i .i i.i i. i i. i i.i
Developmental delay, which is suggested by screening,is a symptom, nota diagnosis. The need for i.i i.i i.i i.i i.i i.i i.i i.i i.i i.i i.i i.i i.i i.i i.i
any therapy would be identifiedwith a comprehensive evaluation, not a screening tool. Some
i.i i.i i.i i.i i.i i.i i.i i.i i.i i.i i.i i.i i.i i.i
providers use the Denver II as a framework for teaching about expected development, but this is
i.i i .i i.i i. i i. i i. i i .i i .i i.i i.i i.i i.i i.i i.i i.i i .i
not the primary purpose of the tool.
i.i i .i i. i i.i i .i i.i i. i
OBJ: NCLEXClientNeedsCategory: HealthPromotionand Maintenance i. i. i. i.i i. i. i.
5. Toplanearlyinterventiona n Nd careforaninfantwithDownsyndrome,thenurseconsiders
i. i. i. i. i. i. i. i. i. i. i. i. i. i.
knowledge of other physical development exemplars such as
i.i i. i i. i i.i i.i i.i i.i i.i
a. cerebralpalsy. i.
b. autism.
c. attention-deficit/hyperactivitydisorder(ADHD). i. i.
d. failureto thrive. i. i.i
ANS: D i . i
Failuretothriveis also a physicaldevelopmentexemplar.Cerebralpalsy is an exemplarof
i. i.i i. i.i i.i i.i i.i i.i i. i.i i.i i.i i.i i.i
motor/developmental delay. Autism is an exemplar of social/emotional developmental delay.
i.i i.i i.i i. i i .i i. i i.i i.i i.i i.i
ADHD is an exemplar of a cognitive disorder.
i.i i. i i .i i. i i.i i. i i.i i.i
OBJ: NCLEXClientNeedsCategory:HealthPromotionand Maintenance i. i.i i. i.i i. i. i.
6. To plan early intervention and carefor a child with a developmental delay, the nurse would
i.i i.i i.i i.i i.i i.i i.i i.i i.i i.i i.i i.i i.i i.i i.i
considerknowledgeoftheconceptsmost significantlyimpactedby development,including
i.i i. i. i. i. i.i i.i i. i. i.i i.i
a. culture.
b. environment.
c. functionalstatus. i.
d. nutrition.
i.i ANS: C i . i
, Functionisoneof the conceptsmost significantlyimpactedby development.Others include i.i i.i i.i i.i i.i i.i i.i i.i i.i i.i i.i i.i
sensory-perceptual, cognition, mobility, reproduction, and sexuality. Knowledge of these
i.i i.i i.i i.i i.i i.i i.i i.i i.i
concepts can help the nurse anticipate areas that need to be addressed. Culture is a concept that is
i.i i.i i. i i.i i .i i.i i.i i.i i.i i.i i .i i .i i. i i.i i.i i.i i.i i.i
considered to significantly affect development; the difference is the concepts that affect
i.i i.i i.i i.i i.i i.i i.i i.i i. i i.i i.i i. i
development are those that represent major influencing factors (causes); hence determination of
i.i i.i i.i i. i i.i i.i i.i i.i i.i i.i i.i i.i
development would be the focus of preventive interventions. Environment is considered to
i.i i.i i.i i.i i .i i.i i.i i.i i.i i.i i.i i. i
significantly affect development. Nutrition is considered to significantly affect development.
i.i i.i i.i i.i i.i i. i i.i i. i i.i i.i
OBJ: NCLEXClientNeedsCategory:HealthPromotionand Maintenance i. i.i i. i.i i. i. i.
7. A mothercomplains to the nurseat the pediatric clinicthat her4-year-old child always talks to her
i.i i. i.i i.i i.i i.i i.i i.i i.i i.i i.i i. i.i i.i i.i i.i i.i
toys and makes up stories. The mother wants her child to have a psychological evaluation. The
i.i i.i i.i i. i i .i i .i i. i i.i i .i i.i i.i i .i i. i i. i i.i i.i
nurse’s best initial response is to
i.i i. i i. i i.i i.i i.i
a. referthechild to a psychologist immediately. i.i i.i i.i i.i i.i i.i
b. explain thatplaying makebelieveis normal at this age. i.i i.i i.i i. i.i i.i i.i i.i i.i
c. completeadevelopmental screening using a validated tool. i. i. i.i i.i i.i i.i i.i
d. separatethe child from the mother toget moreinformation. i. i.i i.i i.i i.i i.i i. i.i i.
ANS: B i . i
By the end of the fourth year, it is expected that a child will engage in fantasy, so this is normal at this
i.i i. i i. i i .i i. i i. i i.i i. i i .i i.i i.i i.i i. i i.i i. i i.i i .i i. i i. i i .i i.i i.i
age. A referral to a psychologist would be premature based only on the complaintof themother.
i.i i. i i.i i.i i. i i. i i.i i. i i. i i.i i.i i.i i. i i.i i. i.i i.
Completingadevelopmental screeningwouldbe very appropriate but not the initial response. The
i.i i.i i.i i.i i.i i.i i.i i. i i.i i.i i .i i. i i.i i.i
nurse would certainly want to get more information, but separating the child from the mother is not
i.i i.i i. i i.i i. i i. i i.i i. i i.i i.i i.i i.i i. i i.i i .i i.i i.i
necessary at this time.
i.i i. i i.i i .i
OBJ: NCLEXClientNeedsNCategory: HealthPromotionand Maintenance i. i. i.i i. i. i.i
8. A 17-year-old girl is hospitalizedforappendicitis,and her mother asks the nursewhy sheis so
i.i i.i i.i i.i i.i i.i i.i i.i i.i i.i i.i i.i i.i i.i i.i i. i
needy and acting like a child. The best response of the nurse is that in the hospital, adolescents
i.i i. i i.i i.i i. i i. i i.i i.i i.i i.i i. i i.i i.i i. i i.i i. i i.i i.i
a. haveseparation anxiety. i. i.i
b. rebelagainst rules. i. i.i
c. regressbecauseofstress. i. i. i.
d. want to know everything. i.i i.i i.i
ANS: C i . i
Regression to an earlier stage of development is a common response to stress. Separation anxiety i.i i. i i. i i.i i.i i .i i.i i.i i.i i.i i. i i. i i.i i.i
is most common in infants and toddlers. Rebellion against hospital rules is usually not an issue if
i.i i.i i.i i. i i.i i .i i .i i. i i.i i.i i.i i.i i. i i.i i.i i.i i.i
the adolescentunderstandsthe rulesand wouldnot createchildlikebehaviors. An adolescent may
i. i.i i.i i.i i.i i.i i.i i.i i.i i. i. i.i i. i i.i
want to “know everything” with their logical thinking and deductive reasoning, but that would
i.i i .i i. i i .i i.i i. i i.i i.i i.i i.i i.i i.i i.i i.i
not explain why they would act like a child.
i.i i .i i.i i.i i .i i.i i. i i.i i. i
OBJ: NCLEXClientNeedsCategory:HealthPromotionand Maintenance i. i.i i. i.i i. i. i.
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