,Concept01:Development
v v
Giddens: Concepts for Nursing Practice, 3rdEdition
v v v v v v
MULTIPLE CHOICE v
1. The nurse manager of a pediatric clinic could confirm that the new nurse recognized the
v v v v v v v v v v v v v v
purpose of the HEADSS Adolescent Risk Profile when the new nurse responds that it is used
v v v v v v v v v v v v v v v v
to review for needs related to
v v v v v v
a. anticipatory guidance. v
b. low-risk adolescents. v
c. physical development. v
d. sexual development. v
ANS: A v
The HEADSS Adolescent Risk Profile is a psychosocial assessment screening tool which
v v v v v v v v v v v
reviews home, education, activities, drugs, sex, and suicide for the purpose of identifying high-
v v v v v v v v v v v v v v
risk adolescents and the need for anticipatory guidance. It is used to identify high-risk, not low-
v v v v v v v v v v v v v v v
risk, adolescents. Physical development is reviewed with anthropometric data.
v v v v v v v v
Sexual development is reviewed using physical examination.
v v v v v v
OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance
v v v v v v v
2. The nurse preparing a teaching plan for a preschooler knows that, according to Piaget, the
v v v v v v v v v v v v v v
expected stage of development for a preschooler is
v v v v v v v v
a. concrete operational. v
b. formaloperational. v
c. preoperational.
d. sensorimotor.
ANS: C v
The expected stage of development for a preschooler (3–4 years old) is pre-operational.
v v v v v v v v v v v v
Concrete operational describes the thinking of a school-age child (7–11 years old). Formal
v v v v v v v v v v v v v
operational describes the thinking of an individual after about 11 years of age. Sensorimotor
v v v v v v v v v v v v v v
describes the earliest pattern of thinking from birth to 2 years old.
v v v v v v v v v v v v
OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance
v v v v v v v
3. The school nurse talking with a high school class about the difference between growth and
v v v v v v v v v v v v v v
development would best describe growth as
v v v v v v
a. processes by which early cells specialize. v v v v v
b. psychosocial and cognitive changes. v v v
c. qualitative changes associated with aging. v v v v
d. quantitative changes insize or weight. v v v v v
v ANS: D v
, Growth is a quantitative change in which an increase in cell number and size results in an
v v v v v v v v v v v v v v v v
increase in overall size or weight of the body or any of its parts. The processes by which early
v v v v v v v v v v v v v v v v v v v
cells specialize are referred to as differentiation. Psychosocial and cognitive changes are
v v v v v v v v v v v v
referred to as development. Qualitative changes associated with aging arereferred to as
v v v v v v v v v v v v v
maturation.
v
OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance v v v v v v v
4. The most appropriate response of the nurse when amother asks what the Denver II does is that it
v v v v v v v v v v v v v v v v v v
a. can diagnose developmental disabilities.
v v v
b. identifies a need for physical therapy. v v v v v
c. is a developmental screening tool.
v v v v
d. provides a 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
v v v v v v v v v v v v v v
professionals; it is a screening tool. Screening tools do not provide adiagnosis. Diagnosis
v v v v v v v v v v v v v v
requires a thorough neurodevelopment history and physical examination.
v v v v v v v v
Developmental delay, which is suggested by screening, is a symptom, not adiagnosis. The need v v v v v v v v v v v v v v
for any therapy would be identified with a comprehensive evaluation, not a screening tool. Some
v v v v v v v v v v v v v v v
providers use the Denver II as a framework for teaching about expected development, but this
v v v v v v v v v v v v v v v
is not the primary purpose of the tool.
v v v v v v v v
OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance v v v v v v v
5. Toplan earlyintervention a n Nd U
v caRreSfIoN
v r aGnTinBf.
anCt OwMith Down syndrome, thenurse considers
v v v v v v v v v
knowledge of other physical development exemplars such as
v v v v v v v v
a. cerebral palsy. v
b. failure to thrive. v v
c. fetal alcohol syndrome. v v
d. hydrocephaly.
ANS: D v
Hydrocephaly is also a physical development exemplar. Cerebral palsy is an exemplar of v v v v v v v v v v v v
adaptive developmental delay. Failure to thrive is an exemplar of social/emotional
v v v v v v v v v v v
developmental delay. Fetal alcohol syndrome is an exemplar of cognitive developmental delay.
v v v v v v v v v v v v
OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance v v v v v v v
6. To plan early intervention and care for a child with a developmental delay, the nurse would
v v v v v v v v v v v v v v v
consider knowledge of the concepts most significantly impacted by development, including
v v v v v v v v v v v
a. culture.
b. environment.
c. functional status. v
d. nutrition.
ANS: C v
, Function is one of the concepts most significantly impacted by development. Others include
v v v v v v v v v v v v
sensory-perceptual, cognition, mobility, reproduction, and sexuality. Knowledge of these
v v v v v v v v v
concepts can help the nurse anticipate areas that need to be addressed. Culture is a concept that
v v v v v v v v v v v v v v v v v
is considered to significantly affect development; the difference is the concepts that affect
v v v v v v v v v v v v v
development are those that represent major influencing factors (causes); hence determination
v v v v v v v v v v v
of development would be the focus of preventive interventions. Environment is considered to
v v v v v v v v v v v v v
significantly affect development. Nutrition is considered to significantly affect development.
v v v v v v v v v v
OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance v v v v v v v
7. A mother complains to the nurse at the pediatric clinic that her 4-year-old child always talks to her
v v v v v v v v v v v v v v v v v
toys and makes up stories. The mother wants her child to have a psychological evaluation. The
v v v v v v v v v v v v v v v v
nurse’s best initial response is to
v v v v v v
a. refer the child to a psychologist immediately. v v v v v v
b. explain that playing make believe is normal at this age. v v v v v v v v v
c. complete a developmental screening using a validated tool. v v v v v v v
d. separate the child from the mother to get more information. 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
v v v v v v v v v v v v v v v v v v v v v
this age. A referral to a psychologist would be premature based only on the complaint of the
v v v v v v v v v v v v v v v v v
mother. Completing a developmental screening would be very appropriate but not the initial
v v v v v v v v v v v v v
response. The nurse would certainly want to get more information, but separating the child
v v v v v v v v v v v v v v
from the mother is not necessary at this time.
v v v v v v v v v
OBJ: NCLEX Client NeedsNCUaRteSgI
o rNy:GHTeBal.thCPOrM
omotion and Maintenance v v v v
8. A 17-year-old girl is hospitalized for appendicitis, and her mother asks the nurse why she is so
v v v v v v v v v v v v v v v v
needy and acting like a child. The best response of the nurse is that in the hospital, adolescents
v v v v v v v v v v v v v v v v v v
a. have separation anxiety. v v
b. rebel against rules. v v
c. regress because of 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. Separationv v v v v v v v v v v v v
anxiety is most common in infants and toddlers. Rebellion against hospital rules is usually not
v v v v v v v v v v v v v v v
an issue if the adolescent understands the rules and would not create childlike behaviors. An
v v v v v v v v v v v v v v v
adolescent may want to “know everything” with their logical thinking and deductive reasoning,
v v v v v v v v v v v v v
but that would not explain why they would act like a child.
v v v v v v v v v v v v
OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance v v v v v v v
v v
Giddens: Concepts for Nursing Practice, 3rdEdition
v v v v v v
MULTIPLE CHOICE v
1. The nurse manager of a pediatric clinic could confirm that the new nurse recognized the
v v v v v v v v v v v v v v
purpose of the HEADSS Adolescent Risk Profile when the new nurse responds that it is used
v v v v v v v v v v v v v v v v
to review for needs related to
v v v v v v
a. anticipatory guidance. v
b. low-risk adolescents. v
c. physical development. v
d. sexual development. v
ANS: A v
The HEADSS Adolescent Risk Profile is a psychosocial assessment screening tool which
v v v v v v v v v v v
reviews home, education, activities, drugs, sex, and suicide for the purpose of identifying high-
v v v v v v v v v v v v v v
risk adolescents and the need for anticipatory guidance. It is used to identify high-risk, not low-
v v v v v v v v v v v v v v v
risk, adolescents. Physical development is reviewed with anthropometric data.
v v v v v v v v
Sexual development is reviewed using physical examination.
v v v v v v
OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance
v v v v v v v
2. The nurse preparing a teaching plan for a preschooler knows that, according to Piaget, the
v v v v v v v v v v v v v v
expected stage of development for a preschooler is
v v v v v v v v
a. concrete operational. v
b. formaloperational. v
c. preoperational.
d. sensorimotor.
ANS: C v
The expected stage of development for a preschooler (3–4 years old) is pre-operational.
v v v v v v v v v v v v
Concrete operational describes the thinking of a school-age child (7–11 years old). Formal
v v v v v v v v v v v v v
operational describes the thinking of an individual after about 11 years of age. Sensorimotor
v v v v v v v v v v v v v v
describes the earliest pattern of thinking from birth to 2 years old.
v v v v v v v v v v v v
OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance
v v v v v v v
3. The school nurse talking with a high school class about the difference between growth and
v v v v v v v v v v v v v v
development would best describe growth as
v v v v v v
a. processes by which early cells specialize. v v v v v
b. psychosocial and cognitive changes. v v v
c. qualitative changes associated with aging. v v v v
d. quantitative changes insize or weight. v v v v v
v ANS: D v
, Growth is a quantitative change in which an increase in cell number and size results in an
v v v v v v v v v v v v v v v v
increase in overall size or weight of the body or any of its parts. The processes by which early
v v v v v v v v v v v v v v v v v v v
cells specialize are referred to as differentiation. Psychosocial and cognitive changes are
v v v v v v v v v v v v
referred to as development. Qualitative changes associated with aging arereferred to as
v v v v v v v v v v v v v
maturation.
v
OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance v v v v v v v
4. The most appropriate response of the nurse when amother asks what the Denver II does is that it
v v v v v v v v v v v v v v v v v v
a. can diagnose developmental disabilities.
v v v
b. identifies a need for physical therapy. v v v v v
c. is a developmental screening tool.
v v v v
d. provides a 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
v v v v v v v v v v v v v v
professionals; it is a screening tool. Screening tools do not provide adiagnosis. Diagnosis
v v v v v v v v v v v v v v
requires a thorough neurodevelopment history and physical examination.
v v v v v v v v
Developmental delay, which is suggested by screening, is a symptom, not adiagnosis. The need v v v v v v v v v v v v v v
for any therapy would be identified with a comprehensive evaluation, not a screening tool. Some
v v v v v v v v v v v v v v v
providers use the Denver II as a framework for teaching about expected development, but this
v v v v v v v v v v v v v v v
is not the primary purpose of the tool.
v v v v v v v v
OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance v v v v v v v
5. Toplan earlyintervention a n Nd U
v caRreSfIoN
v r aGnTinBf.
anCt OwMith Down syndrome, thenurse considers
v v v v v v v v v
knowledge of other physical development exemplars such as
v v v v v v v v
a. cerebral palsy. v
b. failure to thrive. v v
c. fetal alcohol syndrome. v v
d. hydrocephaly.
ANS: D v
Hydrocephaly is also a physical development exemplar. Cerebral palsy is an exemplar of v v v v v v v v v v v v
adaptive developmental delay. Failure to thrive is an exemplar of social/emotional
v v v v v v v v v v v
developmental delay. Fetal alcohol syndrome is an exemplar of cognitive developmental delay.
v v v v v v v v v v v v
OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance v v v v v v v
6. To plan early intervention and care for a child with a developmental delay, the nurse would
v v v v v v v v v v v v v v v
consider knowledge of the concepts most significantly impacted by development, including
v v v v v v v v v v v
a. culture.
b. environment.
c. functional status. v
d. nutrition.
ANS: C v
, Function is one of the concepts most significantly impacted by development. Others include
v v v v v v v v v v v v
sensory-perceptual, cognition, mobility, reproduction, and sexuality. Knowledge of these
v v v v v v v v v
concepts can help the nurse anticipate areas that need to be addressed. Culture is a concept that
v v v v v v v v v v v v v v v v v
is considered to significantly affect development; the difference is the concepts that affect
v v v v v v v v v v v v v
development are those that represent major influencing factors (causes); hence determination
v v v v v v v v v v v
of development would be the focus of preventive interventions. Environment is considered to
v v v v v v v v v v v v v
significantly affect development. Nutrition is considered to significantly affect development.
v v v v v v v v v v
OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance v v v v v v v
7. A mother complains to the nurse at the pediatric clinic that her 4-year-old child always talks to her
v v v v v v v v v v v v v v v v v
toys and makes up stories. The mother wants her child to have a psychological evaluation. The
v v v v v v v v v v v v v v v v
nurse’s best initial response is to
v v v v v v
a. refer the child to a psychologist immediately. v v v v v v
b. explain that playing make believe is normal at this age. v v v v v v v v v
c. complete a developmental screening using a validated tool. v v v v v v v
d. separate the child from the mother to get more information. 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
v v v v v v v v v v v v v v v v v v v v v
this age. A referral to a psychologist would be premature based only on the complaint of the
v v v v v v v v v v v v v v v v v
mother. Completing a developmental screening would be very appropriate but not the initial
v v v v v v v v v v v v v
response. The nurse would certainly want to get more information, but separating the child
v v v v v v v v v v v v v v
from the mother is not necessary at this time.
v v v v v v v v v
OBJ: NCLEX Client NeedsNCUaRteSgI
o rNy:GHTeBal.thCPOrM
omotion and Maintenance v v v v
8. A 17-year-old girl is hospitalized for appendicitis, and her mother asks the nurse why she is so
v v v v v v v v v v v v v v v v
needy and acting like a child. The best response of the nurse is that in the hospital, adolescents
v v v v v v v v v v v v v v v v v v
a. have separation anxiety. v v
b. rebel against rules. v v
c. regress because of 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. Separationv v v v v v v v v v v v v
anxiety is most common in infants and toddlers. Rebellion against hospital rules is usually not
v v v v v v v v v v v v v v v
an issue if the adolescent understands the rules and would not create childlike behaviors. An
v v v v v v v v v v v v v v v
adolescent may want to “know everything” with their logical thinking and deductive reasoning,
v v v v v v v v v v v v v
but that would not explain why they would act like a child.
v v v v v v v v v v v v
OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance v v v v v v v
