Giddens: Concepts for Nursing Practice, 4thEdition
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1. The nurse manager of a pediatric clinic could confirm that the new nurse recognized th
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epurpose of the HEADSS Adolescent Risk Profile when the new nurse responds that it
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isused to assess for needs related to
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a. anticipatory guidance. ki
b. low-risk adolescents. ki
c. physical development. ki
d. sexual development. ki
ANS: A k i
The HEADSS Adolescent Risk Profile is a psychosocial assessment screening tool which a
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ssesses home, education, activities, drugs, sex, and suicide for the purpose of identifying hi
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gh-risk adolescents and the need for anticipatory guidance. It is used to identify high-
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risk,not low-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: NCLEX Client Needs Category: Health Promotion and Maintenance ki ki ki ki ki ki ki
2. The nurse preparing a teaching plan for a preschooler knows that, according to Piaget, th
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eexpected stage of development for a preschooler is
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a. concrete operational. ki
b. formal operational. N ki
c. preoperational.
d. sensorimotor.
ANS: C k i
The expected stage of development for a preschooler (3–4 years old) is pre-
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operational. Concrete operational describes the thinking of a school-age child (7–
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11 years old). Formal operational describes the thinking of an individual after about 11 year
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s of age. Sensorimotordescribes the earliest pattern of thinking from birth to 2 years old.
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OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance ki ki ki ki ki ki ki
3. The school nurse talking with a high school class about the difference between growth an
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ddevelopment would best describe growth as
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a. processes by which early cells specialize. ki ki ki ki ki
b. psychosocial and cognitive changes. ki ki ki
c. qualitative changes associated with aging. ki ki ki ki
d. quantitative changes in size or weight ki ki ki ki ki
.ANS: D
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WWW.NURSYLAB.COM
, Growth is a quantitative change in which an increase in cell number and size results in an
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increase in overall size or weight of the body or any of its parts. The processes by which e
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arly cells specialize are referred to as differentiation. Psychosocial and cognitive changes
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are referred to as development. Qualitative changes associated with aging are referred to a
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smaturation.
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OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance ki ki ki ki ki ki ki
4. The most appropriate response of the nurse when a mother asks what the Denver II does i
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sthat it
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a. can diagnose developmental disabilities.
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b. identifies a need for physical therapy. ki ki ki ki ki
c. is a developmental screening tool.
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d. provides a framework for health teaching. ki ki ki ki ki
ANS: C k i
The Denver II is the most commonly used measure of developmental status used by healt
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hcare professionals; it is a screening tool. Screening tools do not provide a diagnosis.Dia
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gnosis requires a thorough neurodevelopment history and physical examination.
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Developmental delay, which is suggested by screening, is a symptom, not a diagnosis. Th
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eneed for any therapy would be identified with a comprehensive evaluation, not a screenin
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gtool. Some providers use the Denver II as a framework for teaching about expected devel
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opment, but this is not the primary purpose of the tool.
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OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance ki ki ki ki ki ki ki
5. To plan early intervention anN
ki d care for an infant with Down syndrome, the nurse considers
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knowledge of other physical development exemplars such as
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a. cerebral palsy. ki
b. autism.
c. attention-deficit/hyperactivity disorder (ADHD). ki ki
d. failure to thrive. ki ki
ANS: D k i
Failure to thrive is also a physical development exemplar. Cerebral palsy is an exemplar o
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fmotor/developmental delay. Autism is an exemplar of social/emotional developmental de
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lay. ADHD is an exemplar of a cognitive disorder.
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OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance ki ki ki ki ki ki ki
6. To plan early intervention and care for a child with a developmental delay, the nurse woul
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dconsider knowledge of the concepts most significantly impacted by development, includin
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g
a. culture.
b. environment.
c. functional status. ki
d. nutrition. ki
ANS: C k i
, Function is one of the concepts most significantly impacted by development. Others includ
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esensory-
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perceptual, cognition, mobility, reproduction, and sexuality. Knowledge of these concepts c
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an help the nurse anticipate areas that need to be addressed. Culture is a concept that is con
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sidered to significantly affect development; the difference is the concepts that affect develo
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pment are those that represent major influencing factors (causes); hence determination of d
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evelopment would be the focus of preventive interventions. Environment is considered to si
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gnificantly affect development. Nutrition is considered to significantly affect development.
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OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance ki ki ki ki ki ki ki
7. A mother complains to the nurse at the pediatric clinic that her 4-year-
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old child always talksto her toys and makes up stories. The mother wants her child to have
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a psychological evaluation. The nurse‘s best initial response is to
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a. refer the child to a psychologist immediately.
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b. explain that playing make believe is normal at this age. ki ki ki ki ki ki ki ki ki
c. complete a developmental screening using a validated tool. ki ki ki ki ki ki ki
d. separate the child from the mother to get more information. ki ki ki ki ki ki ki ki ki
ANS: B k i
By the end of the fourth year, it is expected that a child will engage in fantasy, so this is no
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rmal at this age. A referral to a psychologist would be premature based only on the compla
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int of the mother. Completing a developmental screening would be very appropriatebut not
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the initial response. The nurse would certainly want to get more information, but separatin
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g the child from the mother is not necessary at this time.
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OBJ: NCLEX Client NeedsNCategory: Health Promotion and Maintenance ki ki ki ki ki ki
8. A 17-year-ki
old girl is hospitalized for appendicitis, and her mother asks the nurse why she isso needy a
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k ki ki
nd acting like a child. The best response of the nurse is that in the hospital, adolescents
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a. have separation anxiety. ki ki
b. rebel against rules. ki ki
c. regress because of stress. ki ki ki
d. want to know everything. ki ki ki
ANS: C k i
Regression to an earlier stage of development is a common response to stress. Separation an
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xiety is most common in infants and toddlers. Rebellion against hospital rules is usually not
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an issue if the adolescent understands the rules and would not create childlike behaviors.An
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adolescent may want to ―know everything‖ with their logical thinking and deductive reason
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ing, but that would not explain why they would act like a child.
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OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance ki ki ki ki ki ki ki
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