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Giddens: Concepts for Nursing Practice, 3rd Edition
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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.
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. N
c. preoperational.
d. sensorimotor.
ANS: | C
The |expected |stage |of |development |for |a |preschooler |(3–4 |years |old) |is |pre-operational.
|Concrete |operational |describes |the |thinking |of |a |school-age |child |(7–11 |years |old). |Formal
|operational |describes |the |thinking |of |an |individual |after |about |11 |years |of |age. |Sensorimotor
|describes |the |earliest |pattern |of |thinking |from |birth |to |2 |years |old.
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
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, 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 |as |differentiation. |Psychosocial |and |cognitive |changes |are
|referred |to |as |development. |Qualitative |changes |associated |with |aging |are |referred |to |as
|maturation.
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 |healthcare
|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 |with |a |comprehensive |evaluation, |not |a |screening |tool.
|Some |providers |use |the |Denver |II |as |a |framework |for |teaching |about |expected |development,
|but |this |is |not |the |primary |purpose |of |the |tool.
OBJ: NCLEX |Client |Needs |Category: |Health |Promotion |and |Maintenance
5. To |plan |early |intervention |a n Nd |care |for |an |infant |with |Down |syndrome, |the |nurse |considers
|knowledge |of |other |physical |development |exemplars |such |as
a. cerebral |palsy.
b. autism.
c. attention-deficit/hyperactivity |disorder |(ADHD).
d. failure |to |thrive.
ANS: | D
Failure |to |thrive |is |also |a |physical |development |exemplar. |Cerebral |palsy |is |an |exemplar |of
|motor/developmental |delay. |Autism |is |an |exemplar |of |social/emotional |developmental
|delay. |ADHD |is |an |exemplar |of |a |cognitive |disorder.
OBJ: NCLEX |Client |Needs |Category: |Health |Promotion |and |Maintenance
6. To |plan |early |intervention |and |care |for |a |child |with |a |developmental |delay, |the |nurse |would
|consider |knowledge |of |the |concepts |most |significantly |impacted |by |development, |including
a. culture.
b. environment.
c. functional |status.
d. nutrition.
ANS: | C
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, Function |is |one |of |the |concepts |most |significantly |impacted |by |development. |Others |include
|sensory-perceptual, |cognition, |mobility, |reproduction, |and |sexuality. |Knowledge |of |these
|concepts |can |help |the |nurse |anticipate |areas |that |need |to |be |addressed. |Culture |is |a |concept
|that |is |considered |to |significantly |affect |development; |the |difference |is |the |concepts |that
|affect |development |are |those |that |represent |major |influencing |factors |(causes); |hence
|determination |of |development |would |be |the |focus |of |preventive |interventions. |Environment
|is |considered |to |significantly |affect |development. |Nutrition |is |considered |to |significantly
|affect |development.
OBJ: NCLEX |Client |Needs |Category: |Health |Promotion |and |Maintenance
7. A |mother |complains |to |the |nurse |at |the |pediatric |clinic |that |her |4-year-old |child |always |talks |to
|her |toys |and |makes |up |stories. |The |mother |wants |her |child |to |have |a |psychological |evaluation.
|The |nurse’s |best |initial |response |is |to
a. refer |the |child |to |a |psychologist |immediately.
b. explain |that |playing |make |believe |is |normal |at |this |age.
c. complete |a |developmental |screening |using |a |validated |tool.
d. separate |the |child |from |the |mother |to |get |more |information.
ANS: | B
By |the |end |of |the |fourth |year, |it |is |expected |that |a |child |will |engage |in |fantasy, |so |this |is |normal
|at |this |age. |A |referral |to |a |psychologist |would |be |premature |based |only |on |the |complaint |of |the
|mother. |Completing |a |developmental |screening |would |be |very |appropriate |but |not |the |initial
|response. |The |nurse |would |certainly |want |to |get |more |information, |but |separating |the |child
|from |the |mother |is |not |necessary |at |this |time.
OBJ: NCLEX |Client |NeedsNCategory: |Health |Promotion |and |Maintenance
8. A |17-year-old |girl |is |hospitalized |for |appendicitis, |and |her |mother |asks |the |nurse |why |she |is |so
|needy |and |acting |like |a |child. |The |best |response |of |the |nurse |is |that |in |the |hospital,
|adolescents
a. have |separation |anxiety.
b. rebel |against |rules.
c. regress |because |of |stress.
d. want |to |know |everything.
ANS: | C
Regression |to |an |earlier |stage |of |development |is |a |common |response |to |stress. |Separation
|anxiety |is |most |common |in |infants |and |toddlers. |Rebellion |against |hospital |rules |is |usually |not
|an |issue |if |the |adolescent |understands |the |rules |and |would |not |create |childlike |behaviors. |An
|adolescent |may |want |to |“know |everything” |with |their |logical |thinking |and |deductive
|reasoning, |but |that |would |not |explain |why |they |would |act |like |a |child.
OBJ: NCLEX |Client |Needs |Category: |Health |Promotion |and |Maintenance
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