Concept 1: Development

Test Bank

MULTIPLE CHOICE

1. The nurse manager of a pediatric clinic could confirm that the new nurse recognized the

purpose of the HEADSS Adolescent Risk Profile when the new nurse responds that it is used

to assess 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

assesses 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 assessed with anthropometric data. Sexual

development is assessed using physical examination.

REF: 6 OBJ: NCLEX® Client Needs Category: Health Promotion and Maintenance

2. 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 to 4 years old) is preoperational.

Concrete operational describes the thinking of a school-age child (7 to 11 years old). Formal

operational describes the thinking of an individual after about 11 years of age. Sensorimotor

describes the earliest pattern of thinking from birth to 2 years old.

REF: 5 OBJ: NCLEX® Client Needs Category: Health Promotion and Maintenance

3. 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

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.

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REF: 2 OBJ: NCLEX® Client Needs Category: Health Promotion and Maintenance

4. 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 health

care 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.

REF: 4 OBJ: NCLEX® Client Needs Category: Health Promotion and Maintenance

5. To plan early intervention and care for an infant with 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.

REF: 9 OBJ: NCLEX® Client Needs Category: Health Promotion and Maintenance

6. 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 and would be the focus of preventive interventions. Environment is

considered to significantly affect development. Nutrition is considered to significantly affect

development.

REF: 1 OBJ: NCLEX® Client Needs Category: Health Promotion and Maintenance

7. 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 psychologic evaluation.

The nurse’s best initial response is to

a. refer the child to a psychologist.

b. explain that playing make believe with dolls and people is normal at this age.

c. complete a developmental screening.

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.

REF: 5 OBJ: NCLEX® Client Needs Category: Health Promotion and Maintenance

8. 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.

REF: 4 OBJ: NCLEX® Client Needs Category: Health Promotion and Maintenance

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Concept 2: Functional Ability

Test Bank

MULTIPLE CHOICE

1. The nurse is assessing a patient's functional ability. Which activities most closely match the

definition of functional ability?

a. Healthy individual, works outside the home, uses a cane, well groomed

b. Healthy individual, college educated, travels frequently, can balance a checkbook

c. Healthy individual, works out, reads well, cooks and cleans house

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, each option has

advanced or independent activities in the context of the option.

REF: 11

OBJ: NCLEX® Client Needs Category: Physiological Integrity: Basic Care and Comfort

2. The nurse is assessing 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. Healthy individual, volunteers at church, works part time, takes care of 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 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.

REF: 11

OBJ: NCLEX® Client Needs Category: Physiological Integrity: Reduction of Risk Potential

3. The nurse is assessing 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

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