,Concept 1: Development
b b
Test Bank
b b
MULTIPLE CHOICE b
1. The nurse manager of a pediatric clinic could confirm that the new nurse recognized the
b b b b b b b b b b b b b b
bpurpose of the HEADSS Adolescent Risk Profile when the new nurse responds that it is used
b b b b b b b b b b b b b b b
bto assess for needs related to
b b b b b
a. anticipatory guidance. b
b. low-risk adolescents. b
c. physical development. b
d. sexual development. b
ANS: A b
The HEADSS Adolescent Risk Profile is a psychosocial assessment screening tool which
b b b b b b b b b b b
assesses home, education, activities, drugs, sex, and suicide for the purpose of identifying
b b b b b b b b b b b b b
high-risk adolescents and the need for anticipatory guidance. It is used to identify high-
b b b b b b b b b b b b b b
risk, not low-risk, adolescents. Physical development is assessed with anthropometric data.
b b b b b b b b b b
Sexual development is assessed using physical examination.
b b b b b b b
REF: b b 6 OBJ: NCLEX® Client Needs Category: Health Promotion and Maintenance
b b b b b b b b
2. The nurse preparing a teaching plan for a preschooler knows that, according to Piaget,
b b b b b b b b b b b b b
bthe expected stage of development for a preschooler is
b b b b b b b b
a. concrete operational. b
b. formal operational. b
c. preoperational.
d. sensorimotor.
ANS: C b
The expected stage of development for a preschooler (3 to 4 years old) is preoperational.
b b b b b b b b b b b b b b
Concrete operational describes the thinking of a school-age child (7 to 11 years old). Formal
b b b b b b b b b b b b b b b
operational describes the thinking of an individual after about 11 years of age.
b b b b b b b b b b b b b
Sensorimotor describes the earliest pattern of thinking from birth to 2 years old.
b b b b b b b b b b b b b
REF: b b 5 OBJ: NCLEX® Client Needs Category: Health Promotion and Maintenance
b b b b b b b b
3. The school nurse talking with a high school class about the difference between growth
b b b b b b b b b b b b b
band development would best describe growth as
b b b b b b
a. processes by which early cells specialize. b b b b b
b. psychosocial and cognitive changes. b b b
c. qualitative changes associated with aging. b b b b
d. quantitative changes in size or weight. b b b b b
ANS: D b
Growth is a quantitative change in which an increase in cell number and size results in an
b b b b b b b b b b b b b b b b
increase in overall size or weight of the body or any of its parts. The processes by which
b b b b b b b b b b b b b b b b b b
early cells specialize are referred to as differentiation. Psychosocial and cognitive changes
b b b b b b b b b b b b
are referred to as development. Qualitative changes associated with aging are referred to
b b b b b b b b b b b b b
as maturation.
b b
, REF: b b 2 OBJ: NCLEX® Client Needs Category: Health Promotion and Maintenance
b b b b b b b b
4. The most appropriate response of the nurse when a mother asks what the Denver II
b b b b b b b b b b b b b b
bdoes is that it b b b
a. can diagnose developmental disabilities.
b b b
b. identifies a need for physical therapy. b b b b b
c. is a developmental screening tool.
b b b b
d. provides a framework for health teaching. b b b b b
ANS: C b
The Denver II is the most commonly used measure of developmental status used by health
b b b b b b b b b b b b b b
care professionals; it is a screening tool. Screening tools do not provide a diagnosis.
b b b b b b b b b b b b b b
Diagnosis requires a thorough neurodevelopment history and physical examination.
b b b b b b b b b
Developmental delay, which is suggested by screening, is a symptom, not a diagnosis. The
b b b b b b b b b b b b b b
need for any therapy would be identified with a comprehensive evaluation, not a screening
b b b b b b b b b b b b b b
tool. Some providers use the Denver II as a framework for teaching about expected
b b b b b b b b b b b b b b
development, but this is not the primary purpose of the tool.
b b b b b b b b b b b
REF: b b 4 OBJ: NCLEX® Client Needs Category: Health Promotion and Maintenance
b b b b b b b b
5. To plan early intervention and care for an infant with Down syndrome, the nurse
b b b b b b b b b b b b b
considers knowledge of other physical development exemplars such as
b b b b b b b b b
a.cerebral palsy. b
b.failure to thrive. b b
c.fetal alcohol syndrome. b b
d.hydrocephaly.
ANS: D b
Hydrocephaly is also a physical development exemplar. Cerebral palsy is an exemplar of
b b b b b b b b b b b b
adaptive developmental delay. Failure to thrive is an exemplar of social/emotional
b b b b b b b b b b b
developmental delay. Fetal alcohol syndrome is an exemplar of cognitive developmental
b b b b b b b b b b b
delay.
b
REF: b b 9 OBJ: NCLEX® Client Needs Category: Health Promotion and Maintenance
b b b b b b b b
6. To plan early intervention and care for a child with a developmental delay, the nurse
b b b b b b b b b b b b b b
bwould consider knowledge of the concepts most significantly impacted by development,
b b b b b b b b b b
bincluding
a. culture.
b. environment.
c. functional status. b
d. nutrition.
ANS: C b
, Function is one of the concepts most significantly impacted by development. Others
b b b b b b b b b b b
include sensory-perceptual, cognition, mobility, reproduction, and sexuality. Knowledge of
b b b b b b b b b
these concepts can help the nurse anticipate areas that need to be addressed. Culture is a
b b b b b b b b b b b b b b b b
concept that is considered to significantly affect development; the difference is the concepts
b b b b b b b b b b b b b
that affect development are those that represent major influencing factors (causes), hence
b b b b b b b b b b b b
determination of development and would be the focus of preventive interventions.
b b b b b b b b b b b
Environment is considered to significantly affect development. Nutrition is considered to
b b b b b b b b b b b
significantly affect development.
b b b
REF: b b 1 OBJ: NCLEX® Client Needs Category: Health Promotion and Maintenance
b b b b b b b b
7. A mother complains to the nurse at the pediatric clinic that her 4-year-old child always talks
b b b b b b b b b b b b b b b
bto her toys and makes up stories. The mother wants her child to have a psychologic
b b b b b b b b b b b b b b b
bevaluation.
The nurse’s best initial response is to
b b b b b b
a. refer the child to a psychologist. b b b b b
b. explain that playing make believe with dolls and people is normal at this age.
b b b b b b b b b b b b b
c. complete a developmental screening. b b b
d. separate the child from the mother to get more information.b b b b b b b b b
ANS: B b
By the end of the fourth year, it is expected that a child will engage in fantasy, so this is
b b b b b b b b b b b b b b b b b b b
normal at this age. A referral to a psychologist would be premature based only on the
b b b b b b b b b b b b b b b b
complaint of the mother. Completing a developmental screening would be very appropriate
b b b b b b b b b b b b
but not the initial response. The nurse would certainly want to get more information, but
b b b b b b b b b b b b b b b
separating the child from the mother is not necessary at this time.
b b b b b b b b b b b b
REF: b b 5 OBJ: NCLEX® Client Needs Category: Health Promotion and Maintenance
b b b b b b b b
8. A 17-year-old girl is hospitalized for appendicitis, and her mother asks the nurse why she is so
b b b b b b b b b b b b b b b b
bneedy and acting like a child. The best response of the nurse is that in the hospital,
b b b b b b b b b b b b b b b b
badolescents
a. have separation anxiety. b b
b. rebel against rules. b b
c. regress because of stress. b b b
d. want to know everything. b b b
ANS: C b
Regression to an earlier stage of development is a common response to stress. Separation
b b b b b b b b b b b b b
anxiety is most common in infants and toddlers. Rebellion against hospital rules is usually
b b b b b b b b b b b b b b
not an issue if the adolescent understands the rules and would not create childlike
b b b b b b b b b b b b b b
behaviors. An adolescent may want to “know everything” with their logical thinking and
b b b b b b b b b b b b b
deductive reasoning, but that would not explain why they would act like a child.
b b b b b b b b b b b b b b
REF: b b 4 OBJ: NCLEX® Client Needs Category: Health Promotion and Maintenance
b b b b b b b b
b b
Test Bank
b b
MULTIPLE CHOICE b
1. The nurse manager of a pediatric clinic could confirm that the new nurse recognized the
b b b b b b b b b b b b b b
bpurpose of the HEADSS Adolescent Risk Profile when the new nurse responds that it is used
b b b b b b b b b b b b b b b
bto assess for needs related to
b b b b b
a. anticipatory guidance. b
b. low-risk adolescents. b
c. physical development. b
d. sexual development. b
ANS: A b
The HEADSS Adolescent Risk Profile is a psychosocial assessment screening tool which
b b b b b b b b b b b
assesses home, education, activities, drugs, sex, and suicide for the purpose of identifying
b b b b b b b b b b b b b
high-risk adolescents and the need for anticipatory guidance. It is used to identify high-
b b b b b b b b b b b b b b
risk, not low-risk, adolescents. Physical development is assessed with anthropometric data.
b b b b b b b b b b
Sexual development is assessed using physical examination.
b b b b b b b
REF: b b 6 OBJ: NCLEX® Client Needs Category: Health Promotion and Maintenance
b b b b b b b b
2. The nurse preparing a teaching plan for a preschooler knows that, according to Piaget,
b b b b b b b b b b b b b
bthe expected stage of development for a preschooler is
b b b b b b b b
a. concrete operational. b
b. formal operational. b
c. preoperational.
d. sensorimotor.
ANS: C b
The expected stage of development for a preschooler (3 to 4 years old) is preoperational.
b b b b b b b b b b b b b b
Concrete operational describes the thinking of a school-age child (7 to 11 years old). Formal
b b b b b b b b b b b b b b b
operational describes the thinking of an individual after about 11 years of age.
b b b b b b b b b b b b b
Sensorimotor describes the earliest pattern of thinking from birth to 2 years old.
b b b b b b b b b b b b b
REF: b b 5 OBJ: NCLEX® Client Needs Category: Health Promotion and Maintenance
b b b b b b b b
3. The school nurse talking with a high school class about the difference between growth
b b b b b b b b b b b b b
band development would best describe growth as
b b b b b b
a. processes by which early cells specialize. b b b b b
b. psychosocial and cognitive changes. b b b
c. qualitative changes associated with aging. b b b b
d. quantitative changes in size or weight. b b b b b
ANS: D b
Growth is a quantitative change in which an increase in cell number and size results in an
b b b b b b b b b b b b b b b b
increase in overall size or weight of the body or any of its parts. The processes by which
b b b b b b b b b b b b b b b b b b
early cells specialize are referred to as differentiation. Psychosocial and cognitive changes
b b b b b b b b b b b b
are referred to as development. Qualitative changes associated with aging are referred to
b b b b b b b b b b b b b
as maturation.
b b
, REF: b b 2 OBJ: NCLEX® Client Needs Category: Health Promotion and Maintenance
b b b b b b b b
4. The most appropriate response of the nurse when a mother asks what the Denver II
b b b b b b b b b b b b b b
bdoes is that it b b b
a. can diagnose developmental disabilities.
b b b
b. identifies a need for physical therapy. b b b b b
c. is a developmental screening tool.
b b b b
d. provides a framework for health teaching. b b b b b
ANS: C b
The Denver II is the most commonly used measure of developmental status used by health
b b b b b b b b b b b b b b
care professionals; it is a screening tool. Screening tools do not provide a diagnosis.
b b b b b b b b b b b b b b
Diagnosis requires a thorough neurodevelopment history and physical examination.
b b b b b b b b b
Developmental delay, which is suggested by screening, is a symptom, not a diagnosis. The
b b b b b b b b b b b b b b
need for any therapy would be identified with a comprehensive evaluation, not a screening
b b b b b b b b b b b b b b
tool. Some providers use the Denver II as a framework for teaching about expected
b b b b b b b b b b b b b b
development, but this is not the primary purpose of the tool.
b b b b b b b b b b b
REF: b b 4 OBJ: NCLEX® Client Needs Category: Health Promotion and Maintenance
b b b b b b b b
5. To plan early intervention and care for an infant with Down syndrome, the nurse
b b b b b b b b b b b b b
considers knowledge of other physical development exemplars such as
b b b b b b b b b
a.cerebral palsy. b
b.failure to thrive. b b
c.fetal alcohol syndrome. b b
d.hydrocephaly.
ANS: D b
Hydrocephaly is also a physical development exemplar. Cerebral palsy is an exemplar of
b b b b b b b b b b b b
adaptive developmental delay. Failure to thrive is an exemplar of social/emotional
b b b b b b b b b b b
developmental delay. Fetal alcohol syndrome is an exemplar of cognitive developmental
b b b b b b b b b b b
delay.
b
REF: b b 9 OBJ: NCLEX® Client Needs Category: Health Promotion and Maintenance
b b b b b b b b
6. To plan early intervention and care for a child with a developmental delay, the nurse
b b b b b b b b b b b b b b
bwould consider knowledge of the concepts most significantly impacted by development,
b b b b b b b b b b
bincluding
a. culture.
b. environment.
c. functional status. b
d. nutrition.
ANS: C b
, Function is one of the concepts most significantly impacted by development. Others
b b b b b b b b b b b
include sensory-perceptual, cognition, mobility, reproduction, and sexuality. Knowledge of
b b b b b b b b b
these concepts can help the nurse anticipate areas that need to be addressed. Culture is a
b b b b b b b b b b b b b b b b
concept that is considered to significantly affect development; the difference is the concepts
b b b b b b b b b b b b b
that affect development are those that represent major influencing factors (causes), hence
b b b b b b b b b b b b
determination of development and would be the focus of preventive interventions.
b b b b b b b b b b b
Environment is considered to significantly affect development. Nutrition is considered to
b b b b b b b b b b b
significantly affect development.
b b b
REF: b b 1 OBJ: NCLEX® Client Needs Category: Health Promotion and Maintenance
b b b b b b b b
7. A mother complains to the nurse at the pediatric clinic that her 4-year-old child always talks
b b b b b b b b b b b b b b b
bto her toys and makes up stories. The mother wants her child to have a psychologic
b b b b b b b b b b b b b b b
bevaluation.
The nurse’s best initial response is to
b b b b b b
a. refer the child to a psychologist. b b b b b
b. explain that playing make believe with dolls and people is normal at this age.
b b b b b b b b b b b b b
c. complete a developmental screening. b b b
d. separate the child from the mother to get more information.b b b b b b b b b
ANS: B b
By the end of the fourth year, it is expected that a child will engage in fantasy, so this is
b b b b b b b b b b b b b b b b b b b
normal at this age. A referral to a psychologist would be premature based only on the
b b b b b b b b b b b b b b b b
complaint of the mother. Completing a developmental screening would be very appropriate
b b b b b b b b b b b b
but not the initial response. The nurse would certainly want to get more information, but
b b b b b b b b b b b b b b b
separating the child from the mother is not necessary at this time.
b b b b b b b b b b b b
REF: b b 5 OBJ: NCLEX® Client Needs Category: Health Promotion and Maintenance
b b b b b b b b
8. A 17-year-old girl is hospitalized for appendicitis, and her mother asks the nurse why she is so
b b b b b b b b b b b b b b b b
bneedy and acting like a child. The best response of the nurse is that in the hospital,
b b b b b b b b b b b b b b b b
badolescents
a. have separation anxiety. b b
b. rebel against rules. b b
c. regress because of stress. b b b
d. want to know everything. b b b
ANS: C b
Regression to an earlier stage of development is a common response to stress. Separation
b b b b b b b b b b b b b
anxiety is most common in infants and toddlers. Rebellion against hospital rules is usually
b b b b b b b b b b b b b b
not an issue if the adolescent understands the rules and would not create childlike
b b b b b b b b b b b b b b
behaviors. An adolescent may want to “know everything” with their logical thinking and
b b b b b b b b b b b b b
deductive reasoning, but that would not explain why they would act like a child.
b b b b b b b b b b b b b b
REF: b b 4 OBJ: NCLEX® Client Needs Category: Health Promotion and Maintenance
b b b b b b b b
