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Concept 01: Development
Giddens: Concepts for Nursing Practice, 3rd Edition
MULTIPLE CHOICE
- The nurse manager of a pediatric clinic could confirm that the new nurse recognized thepurpose
of the HEADSS Adolescent Risk Profile when the new nurse responds that it isused to review
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 reviews
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 reviewed with anthropometric data.
Sexual development is reviewed using physical examination.
OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance - 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.
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. Sensorimotordescribes the
earliest pattern of thinking from birth to 2 years old.
OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance - 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
- 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 - To plan early intervention anNdUcaRreSfIoNr aGnTinBf.anCtOwMith Down syndrome, the nurse considers
knowledge of other physical development exemplars such as
a. cerebral palsy.
b. failure to thrive.
c. fetal alcohol syndrome.
d. hydrocephaly.
ANS: D
Hydrocephaly is also a physical development exemplar. Cerebral palsy is an exemplar of
adaptive developmental delay. Failure to thrive is an exemplar of social/emotional
developmental delay. Fetal alcohol syndrome is an exemplar of cognitive developmental
delay.
OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance - 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
- 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 NeedsNCUaRteSgIorNy:GHTeBa.lthCPOrMomotion and Maintenance - 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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Concept 02: Functional Ability
Giddens: Concepts for Nursing Practice, 3rd Edition
MULTIPLE CHOICE
- The nurse is reviewing a patient’s functional ability. Which patient best demonstrates the
definition of functional ability?
a. Considers self as a healthy individual; uses cane for stability
b. College educated; travels frequently; can balance a checkbook
c. Works out daily, reads well, cooks, and cleans house on the weekends
d. Healthy individual, volunteers at church, works part time, takes care of family and
house
ANS: D
Functional ability refers to the individual’s ability to perform the normal daily activities
required to meet basic needs; fulfill usual roles in the family, workplace, and community;
and maintain health and well-being. The other options are good; however, healthy
individual, church volunteer, part time worker, and the patient who takes care of the family
and house fully meets the criteria for functional ability.
OBJ: NCLEX Client Needs Category: Physiological Integrity: Basic Care and Comfort - The nurse is reviewing a patient’s functional performance. What assessment parameters will
be most important in this assessment?
a. Continence assessment, gait assessment, feeding assessment, dressing assessment,
transfer assessment
b. Height, weight, body mass index (BMI), vital signs assessment
c. Sleep assessment, energy assessment, memory assessment, concentration
assessment
d. Health and well-being, amount of community volunteer time, working outside the
home, and ability to care for family and house
ANS: A
Functional impairment, disability, or handicap refers to varying degrees of an individual’s
inability to perform the tasks required to complete normal life activities without assistance.
Height, weight, BMI, and vital signs are part of a physical assessment. Sleep, energy,
memory, and concentration are part of a depression screening. Healthy, volunteering,
working, and caring for family and house are functional abilities, not performance.
OBJ: NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential - The nurse is reviewing a patient with a mobility dysfunction and wants to gain insight into
the patient’s functional ability. What question would be the most appropriate?
a. “Are you able to shop for yourself?”
b. “Do you use a cane, walker, or wheelchair to ambulate?”
c. “Do you know what today’s date is?”
d. “Were you sad or depressed more than once in the last 3 days?”
ANS: B