1. The hnurse hmanager hof ha hpediatric hclinic hcould hconfirm hthat hthe hnew hnurse
hrecognized hthe hpurpose hof hthe hHEADSS hAdolescent hRisk hProfile hwhen hthe hnew
hnurse hresponds hthat hit his hused hto hassess hfor hneeds hrelated hto
a. anticipatory hguidance.
b. low-risk hadolescents.
c. physical hdevelopment.
d. sexual hdevelopment.
ANS: h A
The hHEADSS hAdolescent hRisk hProfile his ha hpsychosocial hassessment hscreening htool
hwhich hassesses hhome, heducation, hactivities, hdrugs, hsex, hand hsuicide hfor hthe hpurpose
hof hidentifying hhigh-risk hadolescents hand hthe hneed hfor hanticipatory hguidance. hIt his
hused hto hidentify hhigh-risk, hnot hlow-risk, hadolescents. hPhysical hdevelopment his
hassessed hwith hanthropometric hdata.
Sexual hdevelopment his hassessed husing hphysical hexamination.
OBJ: NCLEX hClient hNeeds hCategory: hHealth hPromotion hand hMaintenance
2. The hnurse hpreparing ha hteaching hplan hfor ha hpreschooler hknows hthat, haccording hto
hPiaget, hthe hexpected hstage hof hdevelopment hfor ha hpreschooler his
a. concrete hoperational.
b. formal hoperational. N
c. preoperational.
d. sensorimotor.
ANS: h C
The hexpected hstage hof hdevelopment hfor ha hpreschooler h(3–4 hyears hold) his hpre-
operational. hConcrete hoperational hdescribes hthe hthinking hof ha hschool-age hchild h(7–11
hyears hold). hFormal hoperational hdescribes hthe hthinking hof han hindividual hafter habout h11
hyears hof hage. hSensorimotor hdescribes hthe hearliest hpattern hof hthinking hfrom hbirth hto h2
hyears hold.
OBJ: NCLEX hClient hNeeds hCategory: hHealth hPromotion hand hMaintenance
3. The hschool hnurse htalking hwith ha hhigh hschool hclass habout hthe hdifference hbetween
hgrowth hand hdevelopment hwould hbest hdescribe hgrowth has
a. processes hby hwhich hearly hcells hspecialize.
b. psychosocial hand hcognitive hchanges.
c. qualitative hchanges hassociated hwith haging.
d. quantitative hchanges hin hsize hor
hweight. hANS: h D
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, Growth his ha hquantitative hchange hin hwhich han hincrease hin hcell hnumber hand hsize
hresults hin han hincrease hin hoverall hsize hor hweight hof hthe hbody hor hany hof hits hparts.
hThe hprocesses hby hwhich hearly hcells hspecialize hare hreferred hto has hdifferentiation.
hPsychosocial hand hcognitive hchanges hare hreferred hto has hdevelopment. hQualitative
hchanges hassociated hwith haging hare hreferred hto has hmaturation.
OBJ: NCLEX hClient hNeeds hCategory: hHealth hPromotion hand hMaintenance
4. The hmost happropriate hresponse hof hthe hnurse hwhen ha hmother hasks hwhat hthe hDenver
hII hdoes his hthat hit
a. can hdiagnose hdevelopmental hdisabilities.
b. identifies ha hneed hfor hphysical htherapy.
c. is ha hdevelopmental hscreening htool.
d. provides ha hframework hfor hhealth hteaching.
ANS: h C
The hDenver hII his hthe hmost hcommonly hused hmeasure hof hdevelopmental hstatus hused
hby hhealthcare hprofessionals; hit his ha hscreening htool. hScreening htools hdo hnot hprovide ha
hdiagnosis. hDiagnosis hrequires ha hthorough hneurodevelopment hhistory hand hphysical
hexamination.
Developmental hdelay, hwhich his hsuggested hby hscreening, his ha hsymptom, hnot ha
hdiagnosis. hThe hneed hfor hany htherapy hwould hbe hidentified hwith ha hcomprehensive
hevaluation, hnot ha hscreening htool. hSome hproviders huse hthe hDenver hII has ha hframework
hfor hteaching habout hexpected hdevelopment, hbut hthis his hnot hthe hprimary hpurpose hof
hthe htool.
OBJ: NCLEX hClient hNeeds hCategory: hHealth hPromotion hand hMaintenance
5. To hplan hearly hintervention ha n Nd hcare hfor han hinfant hwith hDown hsyndrome, hthe hnurse
hconsiders hknowledge hof hother hphysical hdevelopment hexemplars hsuch has
a. cerebral hpalsy.
b. autism.
c. attention-deficit/hyperactivity hdisorder h(ADHD).
d. failure hto hthrive.
ANS: h D
Failure hto hthrive his halso ha hphysical hdevelopment hexemplar. hCerebral hpalsy his han
hexemplar hof hmotor/developmental hdelay. hAutism his han hexemplar hof hsocial/emotional
hdevelopmental hdelay. hADHD his han hexemplar hof ha hcognitive hdisorder.
OBJ: NCLEX hClient hNeeds hCategory: hHealth hPromotion hand hMaintenance
6. To hplan hearly hintervention hand hcare hfor ha hchild hwith ha hdevelopmental hdelay, hthe
hnurse hwould hconsider hknowledge hof hthe hconcepts hmost hsignificantly himpacted hby
hdevelopment, hincluding
a. culture.
b. environment.
c. functional hstatus.
d. nutrition.
hANS: h C
, Function his hone hof hthe hconcepts hmost hsignificantly himpacted hby hdevelopment. hOthers
hinclude hsensory-perceptual, hcognition, hmobility, hreproduction, hand hsexuality.
hKnowledge hof hthese hconcepts hcan hhelp hthe hnurse hanticipate hareas hthat hneed hto hbe
haddressed. hCulture his ha hconcept hthat his hconsidered hto hsignificantly haffect
hdevelopment; hthe hdifference his hthe hconcepts hthat haffect hdevelopment hare hthose hthat
hrepresent hmajor hinfluencing hfactors h(causes); hhence hdetermination hof hdevelopment
hwould hbe hthe hfocus hof hpreventive hinterventions. hEnvironment his hconsidered hto
hsignificantly haffect hdevelopment. hNutrition his hconsidered hto hsignificantly haffect
hdevelopment.
OBJ: NCLEX hClient hNeeds hCategory: hHealth hPromotion hand hMaintenance
7. A hmother hcomplains hto hthe hnurse hat hthe hpediatric hclinic hthat hher h4-year-old hchild
halways htalks hto hher htoys hand hmakes hup hstories. hThe hmother hwants hher hchild hto hhave
ha hpsychological hevaluation. hThe hnurse‘s hbest hinitial hresponse his hto
a. refer hthe hchild hto ha hpsychologist himmediately.
b. explain hthat hplaying hmake hbelieve his hnormal hat hthis hage.
c. complete ha hdevelopmental hscreening husing ha hvalidated htool.
d. separate hthe hchild hfrom hthe hmother hto hget hmore hinformation.
ANS: h B
By hthe hend hof hthe hfourth hyear, hit his hexpected hthat ha hchild hwill hengage hin hfantasy, hso
hthis his hnormal hat hthis hage. hA hreferral hto ha hpsychologist hwould hbe hpremature hbased
honly hon hthe hcomplaint hof hthe hmother. hCompleting ha hdevelopmental hscreening hwould
hbe hvery happropriate hbut hnot hthe hinitial hresponse. hThe hnurse hwould hcertainly hwant hto
hget hmore hinformation, hbut hseparating hthe hchild hfrom hthe hmother his hnot hnecessary hat
hthis htime.
OBJ: NCLEX hClient hNeedsNCategory: hHealth hPromotion hand hMaintenance
8. A h17-year-old hgirl his hhospitalized hfor happendicitis, hand hher hmother hasks hthe hnurse
hwhy hshe his hso hneedy hand hacting hlike ha hchild. hThe hbest hresponse hof hthe hnurse his
hthat hin hthe hhospital, hadolescents
a. have hseparation hanxiety.
b. rebel hagainst hrules.
c. regress hbecause hof hstress.
d. want hto hknow heverything.
ANS: h C
Regression hto han hearlier hstage hof hdevelopment his ha hcommon hresponse hto hstress.
hSeparation hanxiety his hmost hcommon hin hinfants hand htoddlers. hRebellion hagainst
hhospital hrules his husually hnot han hissue hif hthe hadolescent hunderstands hthe hrules hand
hwould hnot hcreate hchildlike hbehaviors. hAn hadolescent hmay hwant hto h―know heverything‖
hwith htheir hlogical hthinking hand hdeductive hreasoning, hbut hthat hwould hnot hexplain hwhy
hthey hwould hact hlike ha hchild.
OBJ: NCLEX hClient hNeeds hCategory: hHealth hPromotion hand hMaintenance
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