Test Bank Concepts for Nursing Practice (4TH Ed) by Jean Giddens

,Concept01:Development
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Giddens:ConceptsforNursingPractice,3rdEdition
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MULTIPLECHOICE o,




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
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to assess for needs related to
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a. anticipatoryguidance. o,




b. low-risk adolescents. o,




c. physicaldevelopment. o,




d. sexualdevelopment. o,




ANS: A o ,




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 identify high-risk, not low-
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risk, adolescents. Physical development is assessed with anthropometric data.
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Sexual development is assessed using physical examination.
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OBJ: NCLEXClient NeedsCategory:HealthPromotion andMaintenance o, o, o, o, o, o, o,




2. Thenurse preparing a teaching plan for a preschoolerknows that, according to Piaget, the
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expected stage of development for a preschooler is
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a. concreteoperational. o,




b. formaloperational. N o,




c. preoperational.
d. sensorimotor.
ANS: C o ,




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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describes the thinking of an individual after 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 o, o, o, o, o, o, o,




3. Theschool nurse talking with a high school class about the differencebetween growth and
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development would best describe growth as
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a. processesby which early cells specialize. o, o, o, o, o,




b. psychosocial and cognitivechanges. o, o, o,




c. qualitative changes associated with aging. o, o, o, o,




d. quantitativechangesinsizeorweight. o, o, o, o, o,




o, ANS: D o ,




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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
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specialize are referred to as differentiation. Psychosocial and cognitive changes arereferred to as
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development. Qualitative changes associated with aging are referredto as maturation.
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OBJ: NCLEXClient NeedsCategory:HealthPromotion andMaintenance o, o, o, o, o, o, o,




4. Themost appropriate response of the nurse when a mother asks what the Denver IIdoes is that it
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a. can diagnosedevelopmental disabilities. o, o, o,




b. identifies a need for physical therapy. o, o, o, o, o,




c. is a developmental screening tool.
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d. providesaframework for health teaching. o, o, o, o, o,




ANS: C o ,




The Denver II is the most commonly used measure of developmental status used by healthcare
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professionals; it is a screening tool. Screening tools do not provide a diagnosis. Diagnosis requires a
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thorough neurodevelopment history and physical examination.
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Developmental delay, which is suggested by screening, is a symptom, not a diagnosis. The need for o, o, o, o, o, o, o, o, o, o, o, o, o, o, o,




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
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not the primary purpose of the tool.
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OBJ: NCLEXClientNeedsCategory: HealthPromotion andMaintenance o, o, o, o, o, o, o,




5. Toplanearlyinterventiona n Nd careforaninfantwithDownsyndrome,thenurseconsiders
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knowledge of other physical development exemplars such as
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a. cerebralpalsy. o,




b. autism.
c. attention-deficit/hyperactivitydisorder(ADHD). o, o,




d. failureto thrive. o, o,




ANS: D o ,




Failureto thriveis also a physical development exemplar.Cerebralpalsy is an exemplarof
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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 o, o, o, o, o, o, o,




6. To plan early intervention and carefor a child with adevelopmental delay, the nurse would
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considerknowledgeoftheconceptsmost significantlyimpactedby development,including
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a. culture.
b. environment.
c. functionalstatus. o,




d. nutrition.
ANS: C
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, Function isone of the concepts most significantly impactedby 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 o, o, o, o, o, o, o,




7. A mother complains to the nurse at the pediatric clinic that her 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 apsychologist immediately. o, o, o, o, o, o,




b. explain that playing makebelieveis normal at this age. o, o, o, o, o, o, o, o, o,




c. completeadevelopmental screening using a validated tool. o, o, o, o, o, o, o,




d. separatethe child from the mother toget moreinformation. o, o, o, o, o, o, o, o, o,




ANS: B o ,




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 complaint of themother.
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Completing adevelopmentalscreening 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: HealthPromotionand Maintenance o, o, o, o, o, o,




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. o, o,




b. rebelagainst rules. o, o,




c. regress becauseofstress. o, o, o,




d. want to know everything. o, o, o,




ANS: C o ,




Regression to an earlier stage of development is a common response to stress. Separation anxiety
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is most common in infants and toddlers. Rebellion against hospital rules is usually not an issue if
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the adolescent understandsthe rules and 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 o, o, o, o, o, o, o,




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