vConcepts vfor vNursing vPractice MAIN EXAM 2025v3rd vEdition
MULTIPLE vCHOICE
1. A v17-year-old vgirl vis vhospitalized vfor vappendicitis, vand vher vmother vasks vthe
vnurse vwhy vshe vis vso vneedy vand vacting vlike va vchild. vThe vbest vresponse vof vthe
vnurse vis vthat vin vthe vhospital, vadolescents a. have vseparation vanxiety.
b. rebel vagainst vrules.
c. regress vbecause vof vstress.
d. want vto vknow veverything. ANS: v C
Regression vto van vearlier vstage vof vdevelopment vis va vcommon vresponse vto vstress.
vSeparation vanxiety vis vmost vcommon vin vinfants vand vtoddlers. vRebellion vagainst
vhospital vrules vis vusually vnot van vissue vif vthe vadolescent vunderstands vthe vrules vand
vwould vnot vcreate vchildlike vbehaviors. vAn vadolescent vmay vwant vto v“know
veverything” vwith vtheir vlogical vthinking vand vdeductive vreasoning, vbut vthat vwould vnot
vexplain vwhy vthey vwould vact vlike va vchild.
2. The vnurse vmanager vof va vpediatric vclinic vcould vconfirm vthat vthe vnew vnurse
vrecognized vthe vpurpose vof vthe vHEADSS vAdolescent vRisk vProfile vwhen vthe
vnew vnurse vresponds vthat vit vis vused vto vassess vfor vneeds vrelated vto a. anticipatory
vguidance.
b. low-risk vadolescents.
c. physical vdevelopment.
d. sexual vdevelopment.
ANS: v A
The vHEADSS vAdolescent vRisk vProfile vis va vpsychosocial vassessment vscreening vtool
vwhich vassesses vhome, veducation, vactivities, vdrugs, vsex, vand vsuicide vfor vthe vpurpose
vof videntifying vhigh-risk vadolescents vand vthe vneed vfor vanticipatory vguidance. vIt vis
vused vto videntify vhigh-risk, vnot vlow-risk, vadolescents. vPhysical vdevelopment vis
vassessed vwith vanthropometric vdata.
Sexual vdevelopment vis vassessed vusing vphysical vexamination.
OBJ: NCLEX vClient vNeeds vCategory: vHealth vPromotion vand vMaintenance
3. The vnurse vpreparing va vteaching vplan vfor va vpreschooler vknows vthat, vaccording vto
vPiaget, vthe vexpected vstage vof vdevelopment vfor va vpreschooler vis a. concrete
voperational.
b. formal voperational. N
c. preoperational.
d. sensorimotor. ANS: v C
The vexpected vstage vof vdevelopment vfor va vpreschooler v(3–4 vyears vold) vis
vpreoperational. vConcrete voperational vdescribes vthe vthinking vof va vschool-age vchild
v(7–11 vyears vold). vFormal voperational vdescribes vthe vthinking vof van vindividual vafter
vabout v11 vyears vof vage. vSensorimotor vdescribes vthe vearliest vpattern vof vthinking vfrom
vbirth vto v2 vyears vold.
OBJ: NCLEX vClient vNeeds vCategory: vHealth vPromotion vand vMaintenance
,4. The vschool vnurse vtalking vwith va vhigh vschool vclass vabout vthe vdifference vbetween
vgrowth vand vdevelopment vwould vbest vdescribe vgrowth vas a. processes vby vwhich
vearly vcells vspecialize.
b. psychosocial vand vcognitive vchanges.
c. qualitative vchanges vassociated vwith vaging.
d. quantitative vchanges vin vsize vor vweight. vANS: v D
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Growth vis va vquantitative vchange vin vwhich van vincrease vin vcell vnumber vand vsize vresults
vin van vincrease vin voverall vsize vor vweight vof vthe vbody vor vany vof vits vparts. vThe
vprocesses vby vwhich vearly vcells vspecialize vare vreferred vto vas vdifferentiation.
vPsychosocial vand vcognitive vchanges vare vreferred vto vas vdevelopment. vQualitative
vchanges vassociated vwith vaging vare vreferred vto vas vmaturation.
OBJ: NCLEX vClient vNeeds vCategory: vHealth vPromotion vand vMaintenance
5. The vmost vappropriate vresponse vof vthe vnurse vwhen va vmother vasks vwhat vthe
vDenver vII vdoes vis vthat vit
a. can vdiagnose vdevelopmental vdisabilities.
b. identifies va vneed vfor vphysical vtherapy.
c. is va vdevelopmental vscreening vtool.
d. provides va vframework vfor vhealth vteaching. ANS: v C
The vDenver vII vis vthe vmost vcommonly vused vmeasure vof vdevelopmental vstatus vused
vby vhealthcare vprofessionals; vit vis va vscreening vtool. vScreening vtools vdo vnot vprovide va
vdiagnosis. vDiagnosis vrequires va vthorough vneurodevelopment vhistory vand vphysical
vexamination.
Developmental vdelay, vwhich vis vsuggested vby vscreening, vis va vsymptom, vnot va
vdiagnosis. vThe vneed vfor vany vtherapy vwould vbe videntified vwith va vcomprehensive
vevaluation, vnot va vscreening vtool. vSome vproviders vuse vthe vDenver vII vas va vframework
vfor vteaching vabout vexpected vdevelopment, vbut vthis vis vnot vthe vprimary vpurpose vof vthe
vtool.
OBJ: NCLEX vClient vNeeds vCategory: vHealth vPromotion vand vMaintenance
6. To vplan vearly vintervention vanNd vcare vfor van vinfant vwith vDown vsyndrome, vthe
vnurse vconsiders vknowledge vof vother vphysical vdevelopment vexemplars vsuch vas a.
cerebral vpalsy.
b. autism.
c. attention-deficit/hyperactivity vdisorder v(ADHD).
d. failure vto vthrive.
ANS: v D
, Failure vto vthrive vis valso va vphysical vdevelopment vexemplar. vCerebral vpalsy vis van
vexemplar vof vmotor/developmental vdelay. vAutism vis van vexemplar vof vsocial/emotional
vdevelopmental vdelay. vADHD vis van vexemplar vof va vcognitive vdisorder.
OBJ: NCLEX vClient vNeeds vCategory: vHealth vPromotion vand vMaintenance
7. To vplan vearly vintervention vand vcare vfor va vchild vwith va vdevelopmental vdelay,
vthe vnurse vwould vconsider vknowledge vof vthe vconcepts vmost vsignificantly
vimpacted vby vdevelopment, vincluding a. culture.
b. environment.
c. functional vstatus.
d. nutrition. vANS: v C
, Function vis vone vof vthe vconcepts vmost vsignificantly vimpacted vby vdevelopment. vOthers
vinclude vsensory-perceptual, vcognition, vmobility, vreproduction, vand vsexuality.
vKnowledge vof vthese vconcepts vcan vhelp vthe vnurse vanticipate vareas vthat vneed vto vbe
vaddressed. vCulture vis va vconcept vthat vis vconsidered vto vsignificantly vaffect
vdevelopment; vthe vdifference vis vthe vconcepts vthat vaffect vdevelopment vare vthose vthat
vrepresent vmajor vinfluencing vfactors v(causes); vhence vdetermination vof vdevelopment
vwould vbe vthe vfocus vof vpreventive vinterventions. vEnvironment vis vconsidered vto
vsignificantly vaffect vdevelopment. vNutrition vis vconsidered vto vsignificantly vaffect
vdevelopment.
OBJ: NCLEX vClient vNeeds vCategory: vHealth vPromotion vand vMaintenance
8. A vmother vcomplains vto vthe vnurse vat vthe vpediatric vclinic vthat vher v4-year-old vchild
valways vtalks vto vher vtoys vand vmakes vup vstories. vThe vmother vwants vher vchild vto
vhave va vpsychological vevaluation. vThe vnurse’s vbest vinitial vresponse vis vto a. refer
vthe vchild vto va vpsychologist vimmediately.
b. explain vthat vplaying vmake vbelieve vis vnormal vat vthis vage.
c. complete va vdevelopmental vscreening vusing va vvalidated vtool.
d. separate vthe vchild vfrom vthe vmother vto vget vmore vinformation.
ANS: v B
By vthe vend vof vthe vfourth vyear, vit vis vexpected vthat va vchild vwill vengage vin vfantasy, vso
vthis vis vnormal vat vthis vage. vA vreferral vto va vpsychologist vwould vbe vpremature vbased
vonly von vthe vcomplaint vof vthe vmother. vCompleting va vdevelopmental vscreening vwould
vbe vvery vappropriate vbut vnot vthe vinitial vresponse. vThe vnurse vwould vcertainly vwant vto
vget vmore vinformation, vbut vseparating vthe vchild vfrom vthe vmother vis vnot vnecessary vat
vthis vtime.
OBJ: NCLEX vClient vNeedsNCategory: vHealth vPromotion vand vMaintenance
OBJ: NCLEX vClient vNeeds vCategory: vHealth vPromotion vand vMaintenance
Concept v02: vFunctional vAbility
Giddens: vConcepts vfor vNursing vPractice, v3rd vEdition
MULTIPLE vCHOICE
1. The vnurse vis vassessing va vpatient’s vfunctional vability. vWhich vpatient vbest vdemonstrates
vthe vdefinition vof vfunctional vability?
a. Considers vself vas va vhealthy vindividual; vuses vcane vfor vstability
b. College veducated; vtravels vfrequently; vcan vbalance va vcheckbook
c. Works vout vdaily, vreads vwell, vcooks, vand vcleans vhouse von vthe vweekends
d. Healthy vindividual, vvolunteers vat vchurch, vworks vpart vtime, vtakes vcare vof vfamily
vand vhouse
ANS: v D
Functional vability vrefers vto vthe vindividual’s vability vto vperform vthe vnormal vdaily
vactivities vrequired vto vmeet vbasic vneeds; vfulfill vusual vroles vin vthe vfamily, vworkplace,
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MULTIPLE vCHOICE
1. A v17-year-old vgirl vis vhospitalized vfor vappendicitis, vand vher vmother vasks vthe
vnurse vwhy vshe vis vso vneedy vand vacting vlike va vchild. vThe vbest vresponse vof vthe
vnurse vis vthat vin vthe vhospital, vadolescents a. have vseparation vanxiety.
b. rebel vagainst vrules.
c. regress vbecause vof vstress.
d. want vto vknow veverything. ANS: v C
Regression vto van vearlier vstage vof vdevelopment vis va vcommon vresponse vto vstress.
vSeparation vanxiety vis vmost vcommon vin vinfants vand vtoddlers. vRebellion vagainst
vhospital vrules vis vusually vnot van vissue vif vthe vadolescent vunderstands vthe vrules vand
vwould vnot vcreate vchildlike vbehaviors. vAn vadolescent vmay vwant vto v“know
veverything” vwith vtheir vlogical vthinking vand vdeductive vreasoning, vbut vthat vwould vnot
vexplain vwhy vthey vwould vact vlike va vchild.
2. The vnurse vmanager vof va vpediatric vclinic vcould vconfirm vthat vthe vnew vnurse
vrecognized vthe vpurpose vof vthe vHEADSS vAdolescent vRisk vProfile vwhen vthe
vnew vnurse vresponds vthat vit vis vused vto vassess vfor vneeds vrelated vto a. anticipatory
vguidance.
b. low-risk vadolescents.
c. physical vdevelopment.
d. sexual vdevelopment.
ANS: v A
The vHEADSS vAdolescent vRisk vProfile vis va vpsychosocial vassessment vscreening vtool
vwhich vassesses vhome, veducation, vactivities, vdrugs, vsex, vand vsuicide vfor vthe vpurpose
vof videntifying vhigh-risk vadolescents vand vthe vneed vfor vanticipatory vguidance. vIt vis
vused vto videntify vhigh-risk, vnot vlow-risk, vadolescents. vPhysical vdevelopment vis
vassessed vwith vanthropometric vdata.
Sexual vdevelopment vis vassessed vusing vphysical vexamination.
OBJ: NCLEX vClient vNeeds vCategory: vHealth vPromotion vand vMaintenance
3. The vnurse vpreparing va vteaching vplan vfor va vpreschooler vknows vthat, vaccording vto
vPiaget, vthe vexpected vstage vof vdevelopment vfor va vpreschooler vis a. concrete
voperational.
b. formal voperational. N
c. preoperational.
d. sensorimotor. ANS: v C
The vexpected vstage vof vdevelopment vfor va vpreschooler v(3–4 vyears vold) vis
vpreoperational. vConcrete voperational vdescribes vthe vthinking vof va vschool-age vchild
v(7–11 vyears vold). vFormal voperational vdescribes vthe vthinking vof van vindividual vafter
vabout v11 vyears vof vage. vSensorimotor vdescribes vthe vearliest vpattern vof vthinking vfrom
vbirth vto v2 vyears vold.
OBJ: NCLEX vClient vNeeds vCategory: vHealth vPromotion vand vMaintenance
,4. The vschool vnurse vtalking vwith va vhigh vschool vclass vabout vthe vdifference vbetween
vgrowth vand vdevelopment vwould vbest vdescribe vgrowth vas a. processes vby vwhich
vearly vcells vspecialize.
b. psychosocial vand vcognitive vchanges.
c. qualitative vchanges vassociated vwith vaging.
d. quantitative vchanges vin vsize vor vweight. vANS: v D
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Growth vis va vquantitative vchange vin vwhich van vincrease vin vcell vnumber vand vsize vresults
vin van vincrease vin voverall vsize vor vweight vof vthe vbody vor vany vof vits vparts. vThe
vprocesses vby vwhich vearly vcells vspecialize vare vreferred vto vas vdifferentiation.
vPsychosocial vand vcognitive vchanges vare vreferred vto vas vdevelopment. vQualitative
vchanges vassociated vwith vaging vare vreferred vto vas vmaturation.
OBJ: NCLEX vClient vNeeds vCategory: vHealth vPromotion vand vMaintenance
5. The vmost vappropriate vresponse vof vthe vnurse vwhen va vmother vasks vwhat vthe
vDenver vII vdoes vis vthat vit
a. can vdiagnose vdevelopmental vdisabilities.
b. identifies va vneed vfor vphysical vtherapy.
c. is va vdevelopmental vscreening vtool.
d. provides va vframework vfor vhealth vteaching. ANS: v C
The vDenver vII vis vthe vmost vcommonly vused vmeasure vof vdevelopmental vstatus vused
vby vhealthcare vprofessionals; vit vis va vscreening vtool. vScreening vtools vdo vnot vprovide va
vdiagnosis. vDiagnosis vrequires va vthorough vneurodevelopment vhistory vand vphysical
vexamination.
Developmental vdelay, vwhich vis vsuggested vby vscreening, vis va vsymptom, vnot va
vdiagnosis. vThe vneed vfor vany vtherapy vwould vbe videntified vwith va vcomprehensive
vevaluation, vnot va vscreening vtool. vSome vproviders vuse vthe vDenver vII vas va vframework
vfor vteaching vabout vexpected vdevelopment, vbut vthis vis vnot vthe vprimary vpurpose vof vthe
vtool.
OBJ: NCLEX vClient vNeeds vCategory: vHealth vPromotion vand vMaintenance
6. To vplan vearly vintervention vanNd vcare vfor van vinfant vwith vDown vsyndrome, vthe
vnurse vconsiders vknowledge vof vother vphysical vdevelopment vexemplars vsuch vas a.
cerebral vpalsy.
b. autism.
c. attention-deficit/hyperactivity vdisorder v(ADHD).
d. failure vto vthrive.
ANS: v D
, Failure vto vthrive vis valso va vphysical vdevelopment vexemplar. vCerebral vpalsy vis van
vexemplar vof vmotor/developmental vdelay. vAutism vis van vexemplar vof vsocial/emotional
vdevelopmental vdelay. vADHD vis van vexemplar vof va vcognitive vdisorder.
OBJ: NCLEX vClient vNeeds vCategory: vHealth vPromotion vand vMaintenance
7. To vplan vearly vintervention vand vcare vfor va vchild vwith va vdevelopmental vdelay,
vthe vnurse vwould vconsider vknowledge vof vthe vconcepts vmost vsignificantly
vimpacted vby vdevelopment, vincluding a. culture.
b. environment.
c. functional vstatus.
d. nutrition. vANS: v C
, Function vis vone vof vthe vconcepts vmost vsignificantly vimpacted vby vdevelopment. vOthers
vinclude vsensory-perceptual, vcognition, vmobility, vreproduction, vand vsexuality.
vKnowledge vof vthese vconcepts vcan vhelp vthe vnurse vanticipate vareas vthat vneed vto vbe
vaddressed. vCulture vis va vconcept vthat vis vconsidered vto vsignificantly vaffect
vdevelopment; vthe vdifference vis vthe vconcepts vthat vaffect vdevelopment vare vthose vthat
vrepresent vmajor vinfluencing vfactors v(causes); vhence vdetermination vof vdevelopment
vwould vbe vthe vfocus vof vpreventive vinterventions. vEnvironment vis vconsidered vto
vsignificantly vaffect vdevelopment. vNutrition vis vconsidered vto vsignificantly vaffect
vdevelopment.
OBJ: NCLEX vClient vNeeds vCategory: vHealth vPromotion vand vMaintenance
8. A vmother vcomplains vto vthe vnurse vat vthe vpediatric vclinic vthat vher v4-year-old vchild
valways vtalks vto vher vtoys vand vmakes vup vstories. vThe vmother vwants vher vchild vto
vhave va vpsychological vevaluation. vThe vnurse’s vbest vinitial vresponse vis vto a. refer
vthe vchild vto va vpsychologist vimmediately.
b. explain vthat vplaying vmake vbelieve vis vnormal vat vthis vage.
c. complete va vdevelopmental vscreening vusing va vvalidated vtool.
d. separate vthe vchild vfrom vthe vmother vto vget vmore vinformation.
ANS: v B
By vthe vend vof vthe vfourth vyear, vit vis vexpected vthat va vchild vwill vengage vin vfantasy, vso
vthis vis vnormal vat vthis vage. vA vreferral vto va vpsychologist vwould vbe vpremature vbased
vonly von vthe vcomplaint vof vthe vmother. vCompleting va vdevelopmental vscreening vwould
vbe vvery vappropriate vbut vnot vthe vinitial vresponse. vThe vnurse vwould vcertainly vwant vto
vget vmore vinformation, vbut vseparating vthe vchild vfrom vthe vmother vis vnot vnecessary vat
vthis vtime.
OBJ: NCLEX vClient vNeedsNCategory: vHealth vPromotion vand vMaintenance
OBJ: NCLEX vClient vNeeds vCategory: vHealth vPromotion vand vMaintenance
Concept v02: vFunctional vAbility
Giddens: vConcepts vfor vNursing vPractice, v3rd vEdition
MULTIPLE vCHOICE
1. The vnurse vis vassessing va vpatient’s vfunctional vability. vWhich vpatient vbest vdemonstrates
vthe vdefinition vof vfunctional vability?
a. Considers vself vas va vhealthy vindividual; vuses vcane vfor vstability
b. College veducated; vtravels vfrequently; vcan vbalance va vcheckbook
c. Works vout vdaily, vreads vwell, vcooks, vand vcleans vhouse von vthe vweekends
d. Healthy vindividual, vvolunteers vat vchurch, vworks vpart vtime, vtakes vcare vof vfamily
vand vhouse
ANS: v D
Functional vability vrefers vto vthe vindividual’s vability vto vperform vthe vnormal vdaily
vactivities vrequired vto vmeet vbasic vneeds; vfulfill vusual vroles vin vthe vfamily, vworkplace,
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