verified questions with 100% correct answers with comprehensive details
GRADE A+
Chapter 1 . Advanced Practice Nursing: Doing What Has to Be Done-Radicals, Renegades, andRebels
MULTIPLE CHOICE
1. The nurse manager of a pediatric clinic could confirm that the new nurse recognized the purpose
of 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 assesses
home, 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, the
expected 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. Concrete
operational 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 and
development 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 increase
in overall size or weight of the body or any of its parts. The processes by which early cells
specialize are referred to asdifferentiation. Psychosocial and cognitive changes are referred to as
development. Qualitative changes associated with aging are referred to as maturation.
REF: 2 OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance
4. The most appropriate response of the nurse when a mother asks what the Denver II does is that it
a. can diagnose developmental disabilities.
b. identifies a need for physical therapy.
c. is a developmental screening tool.
d. provides a framework for health teaching.
ANS: C
The Denver II is the most commonly used measure of developmental status used by health care
professionals; it is a screening tool. Screening tools do not provide a diagnosis. Diagnosis requires a
thorough neurodevelopment history and physical examination. Developmental delay, which is
suggested by screening, is a symptom, not a diagnosis. The need for any therapy would be
,identified fwith fa fcomprehensive fevaluation, fnot fa fscreening ftool. fSome fproviders fuse fthe
fDenver fII fas fa fframework ffor fteaching fabout fexpected fdevelopment, fbut fthis fis fnot fthe
fprimary fpurpose fof fthe ftool.
REF: f4 fOBJ: fNCLEX fClient fNeeds fCategory: fHealth fPromotion fand fMaintenance
5. To fplan fearly fintervention fand fcare ffor fan finfant fwith fDown fsyndrome, fthe fnurse
fconsidersfknowledge fof fother fphysical fdevelopment f exemplars fsuch fas
a. cerebral fpalsy.
b. failure fto fthrive.
c. fetal falcohol fsyndrome.
d. hydrocephaly.
ANS: fD
Hydrocephaly fis falso fa fphysical fdevelopment fexemplar. fCerebral fpalsy fis fan fexemplar fof
fadaptivefdevelopmental fdelay. fFailure fto fthrive fis fan fexemplar fof fsocial/emotional fdevelopmental
fdelay.
Fetal falcohol fsyndrome fis fan fexemplar fof fcognitive fdevelopmental fdelay.
REF: f9 fOBJ: fNCLEX fClient fNeeds fCategory: fHealth fPromotion fand fMaintenance
6. To fplan fearly fintervention fand fcare ffor fa fchild fwith fa fdevelopmental fdelay, fthe fnurse
f wouldfconsider fknowledge fof fthe fconcepts fmost fsignificantly fimpacted fby fdevelopment,
fincluding
a. culture.
b. environment.
c. functional fstatus.
d. nutrition.
ANS: fC
Function fis fone fof fthe fconcepts fmost fsignificantly fimpacted fby fdevelopment. fOthers finclude
fsensory-perceptual, fcognition, fmobility, freproduction, fand fsexuality. fKnowledge fof fthese
fconcepts fcan fhelp fthe fnurse fanticipate fareas fthat fneed fto fbe faddressed. fCulture fis fa fconcept
fthat fis fconsidered fto fsignificantly faffect fdevelopment; fthe fdifference fis fthe fconcepts fthat faffect
fdevelopment fare fthose fthat frepresent fmajor finfluencing ffactors f(causes), fhence fdetermination fof
, fdevelopment fand fwould fbefthe ffocus fof fpreventive finterventions. fEnvironment fis fconsidered fto
fsignificantly faffect fdevelopment. fNutrition fis fconsidered fto fsignificantly faffect f development.
REF: f1 fOBJ: fNCLEX fClient fNeeds fCategory: fHealth fPromotion fand fMaintenance
7. A fmother fcomplains fto fthe fnurse fat fthe fpediatric fclinic fthat fher f4-year-old fchild falways
ftalks fto fher ftoys fand fmakes fup fstories. fThe fmother fwants fher fchild fto fhave fa fpsychologic
fevaluation. fThefnurses fbest f initial fresponse f is fto
a. refer fthe fchild fto fa fpsychologist.
b. explain fthat fplaying fmake fbelieve fwith fdolls fand fpeople fis fnormal fat fthis fage.
c. complete fa fdevelopmental fscreening.
d. separate fthe fchild ffrom fthe fmother fto fget fmore finformation.
ANS: fB
By fthe fend fof fthe ffourth fyear, fit fis fexpected fthat fa fchild fwill fengage fin ffantasy, fso fthis fis
fnormal fat fthis fage. fA freferral fto fa fpsychologist fwould fbe fpremature fbased fonly fon fthe
fcomplaint fof fthe fmother. fCompleting fa fdevelopmental fscreening fwould fbe fvery fappropriate
fbut fnot fthe finitial fresponse. fThe fnurse fwould fcertainly fwant fto fget fmore finformation, fbut
fseparating fthe fchild ffrom fthefmother f is fnot fnecessary fat f this ftime.
REF: f5 fOBJ: fNCLEX fClient fNeeds fCategory: fHealth fPromotion fand fMaintenance
8. A f17-year-old fgirl fis fhospitalized ffor fappendicitis, fand fher fmother fasks fthe fnurse fwhy fshe
fis fso fneedy fand facting flike fa fchild. fThe fbest f response fof fthe fnurse fis fthat fin fthe fhospital,
fadolescents
a. have fseparation fanxiety.
b. rebel fagainst frules.
c. regress fbecause fof fstress.
d. want fto fknow feverything.
ANS: fC
Regression fto fan fearlier fstage fof fdevelopment fis fa fcommon fresponse fto fstress. fSeparation
fanxiety fisfmost fcommon fin finfants fand ftoddlers. fRebellion fagainst fhospital frules fis fusually fnot
fan fissue fif fthe fadolescent funderstands fthe frules fand fwould fnot fcreate fchildlike fbehaviors. fAn
fadolescent fmay fwantfto fknow feverything fwith ftheir flogical fthinking fand fdeductive freasoning,