Wong’s Essentials of Pediatric Nursing 9th Edition By Marilyn J. Hockenberry – Test Bank

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Chapter 05: Developmental and Genetic Influences on Child Health Promotion

MULTIPLE CHOICE

1. 2. 3. An infant gains head control before sitting unassisted. The nurse recognizes that this is which

type of development?

a. Cephalocaudal

b. Proximodistal

c. Mass to specific

d. Sequential

ANS: A

The pattern of development that is head-to-tail, or cephalocaudal, direction is described by an

infant’s ability to gain head control before sitting unassisted. The head end of the organism

develops first and is large and complex, whereas the lower end is smaller and simpler, and

development takes place at a later time. Proximodistal, or near to far, is another pattern of

development. Limb buds develop before fingers and toes. Postnatally, the child has control of

the shoulder before achieving mastery of the hands. Mass to specific is not a specific pattern

of development. In all dimensions of growth, a definite, sequential pattern is followed.

PTS: 1 DIF: Cognitive Level: Understand REF: 65

TOP: Integrated Process: Nursing Process: Assessment

MSC: Area of Client Needs: Health Promotion and Maintenance

Which refers to those times in an individual’s life when he or she is more susceptible to

positive or negative influences?

a. Sensitive period

b. Sequential period

c. Terminal points

d. Differentiation points

ANS: A

Sensitive periods are limited times during the process of growth when the organism will

interact with a particular environment in a specific manner. These times make the organism

more susceptible to positive or negative influences. The sequential period, terminal points,

and differentiation points are developmental times that do not make the organism more

susceptible to environmental interaction.

PTS: 1 DIF: Cognitive Level: Remember REF: 66

TOP: Integrated Process: Nursing Process: Planning

MSC: Area of Client Needs: Health Promotion and Maintenance

An infant who weighs 7 pounds at birth would be expected to weigh how many pounds at age

1 year?

a. 14

b. 16

c. 18

d. 21

ANS: D4. 5. 6. In general, birth weight triples by the end of the first year of life. For an infant who was 7

pounds at birth, 21 pounds would be the anticipated weight at the first birthday; 14, 16, or 18

pounds is below what would be expected for an infant with a birth weight of 7 pounds.

PTS: 1 DIF: Cognitive Level: Understand REF: 67

TOP: Integrated Process: Nursing Process: Assessment

MSC: Area of Client Needs: Health Promotion and Maintenance

By what age does birth length usually double?

a. 1 year

b. 2 years

c. 4 years

d. 6 years

ANS: C

Linear growth or height occurs almost entirely as a result of skeletal growth and is considered

a stable measurement of general growth. On average, most children have doubled their birth

length at age 4 years. One and 2 years are too young for doubling of length. Most children

will have achieved the doubling by age 4 years.

PTS: 1 DIF: Cognitive Level: Remember REF: 68

TOP: Integrated Process: Nursing Process: Assessment

MSC: Area of Client Needs: Health Promotion and Maintenance

Parents of an 8-year-old child ask the nurse how many inches their child should grow each

year. The nurse bases the answer on the knowledge that after age 7 years, school-age children

usually grow what number of inches per year?

a. 1

b. 2

c. 3

d. 4

ANS: B

The growth velocity after age 7 years is approximately 5 cm (2 inches) per year. One inch is

too small an amount. Three and 4 inches are greater than the average yearly growth after age 7

years.

PTS: 1 DIF: Cognitive Level: Apply REF: 68

TOP: Integrated Process: Nursing Process: Implementation

MSC: Area of Client Needs: Health Promotion and Maintenance

Parents express concern that their pubertal daughter is taller than the boys in her class. The

nurse should respond with which statement regarding how the onset of pubertal growth spurt

compares in girls and boys?

a. b. c. d. It occurs earlier in boys.

It occurs earlier in girls.

It is about the same in both boys and girls.

In both boys and girls, the pubertal growth spurt depends on growth in infancy.

ANS: B7. 8. 9. Usually, the pubertal growth spurt begins earlier in girls. It typically occurs between the ages

of 10 and 14 years for girls and 11 and 16 years for boys. The average earliest age at onset is 1

year earlier for girls. There does not appear to be a relation to growth during infancy.

PTS: 1 DIF: Cognitive Level: Apply REF: 68

TOP: Integrated Process: Nursing Process: Implementation

MSC: Area of Client Needs: Health Promotion and Maintenance

A 13-year-old girl asks the nurse how much taller she will get. She has been growing about 2

inches per year but grew 4 inches this past year. Menarche recently occurred. The nurse

should base her response on which statement?

a. Growth cannot be predicted.

b. Pubertal growth spurt lasts about 1 year.

c. Mature height is achieved when menarche occurs.

d. Approximately 95% of mature height is achieved when menarche occurs.

ANS: D

At the time of the beginning of menstruation or the skeletal age of 13 years, most girls have

grown to about 95% of their adult height. They may have some additional growth (5%) until

the epiphyseal plates are closed. Although growth cannot be definitively predicted, on

average, 95% of adult height has been reached with the onset of menstruation. Pubertal

growth spurt lasts about 1 year does not address the girl’s question. Young women usually

will grow approximately 5% more after the onset of menstruation.

PTS: 1 DIF: Cognitive Level: Apply REF: 68

TOP: Integrated Process: Teaching/Learning

MSC: Area of Client Needs: Health Promotion and Maintenance

A child’s skeletal age is best determined by:

a. assessment of dentition.

b. assessment of height over time.

c. facial bone development.

d. radiographs of the hand and wrist.

ANS: D

The most accurate measure of skeletal age is radiologic examinations of the growth plates.

These are the epiphyseal cartilage plates. Radiographs of the hand and wrist provide the most

useful screening to determine skeletal age. Age of tooth eruption has considerable variation in

children. It would not be a good determinant of skeletal age. Assessment of height over time

will provide a record of the child’s height but not skeletal age. Facial bone development will

not reflect the child’s skeletal age, which is determined by radiographic assessment.

PTS: 1 DIF: Cognitive Level: Remember REF: 68

TOP: Integrated Process: Nursing Process: Assessment

MSC: Area of Client Needs: Health Promotion and Maintenance

Trauma to which site can result in a growth problem for children’s long bones?

a. Matrix

b. Connective tissue

c. Calcified cartilage

d. Epiphyseal cartilage plate10. 11. 12. ANS: D

The epiphyseal cartilage plate is the area of active growth. Bone injury at the epiphyseal plate

can significantly affect subsequent growth and development. Trauma or infection can result in

deformity. The matrix, connective tissue, and calcified cartilage are not areas of active growth.

Trauma in these sites will not result in growth problems for the long bones.

PTS: 1 DIF: Cognitive Level: Comprehend REF: 68

TOP: Integrated Process: Nursing Process: Assessment

MSC: Area of Client Needs: Health Promotion and Maintenance

A nurse has completed a teaching session for adolescents regarding lymphoid tissue growth.

Which statement, by the adolescents, indicates understanding of the teaching?

a. b. c. d. The tissue reaches adult size by age 1 year.

The tissue quits growing by 6 years of age.

The tissue is poorly developed at birth.

The tissue is twice the adult size by ages 10 to 12 years.

ANS: D

Lymphoid tissue continues growing until it reaches maximal development at ages 10 to 12

years, which is twice its adult size. A rapid decline in size occurs until it reaches adult size by

the end of adolescence. The tissue reaches adult size at 6 years of age but continues to grow.

The tissue is well developed at birth.

PTS: 1 DIF: Cognitive Level: Analyze REF: 68-69

TOP: Integrated Process: Nursing Process: Evaluation

MSC: Area of Client Needs: Health Promotion and Maintenance

Which statement is true about the basal metabolic rate (BMR) in children?

a. b. c. d. It is reduced by fever.

It is slightly higher in boys than in girls at all ages.

It increases with age of child.

It decreases as proportion of surface area to body mass increases.

ANS: B

The BMR is the rate of metabolism when the body is at rest. At all ages, the rate is slightly

higher in boys than in girls. The rate is increased by fever. The BMR is highest in infancy and

then closely relates to the proportion of surface area to body mass. As the child grows, the

proportion decreases progressively to maturity.

PTS: 1 DIF: Cognitive Level: Understand REF: 69

TOP: Integrated Process: Nursing Process: Assessment

MSC: Area of Client Needs: Health Promotion and Maintenance: Growth and Development

A mother reports that her 6-year-old child is highly active, irritable, and irregular in habits and

that the child adapts slowly to new routines, people, or situations. The nurse should chart this

type of temperament as:

a. easy.

b. difficult.

c. slow-to-warm.

d. fast-to-warm.

ANS: B13. 14. Being highly active, irritable, irregular in habits, and adapting slowly to new routines, people,

or situations is a description of difficult children, which compose about 10% of the

population. Negative withdrawal responses are typical of this type of child, who requires a

more structured environment. Mood expressions are usually intense and primarily negative.

These children exhibit frequent periods of crying and often violent tantrums. Easy children are

even tempered, regular, and predictable in their habits. They are open and adaptable to change.

Approximately 40% of children fit this description. Slow-to-warm-up children typically react

negatively and with mild intensity to new stimuli and adapt slowly with repeated contact.

Approximately 10% of children fit this description. “Fast-to-warm-up” is not one of the

categories identified.

PTS: 1 DIF: Cognitive Level: Apply REF: 70

TOP: Integrated Process: Communication and Documentation

MSC: Area of Client Needs: Health Promotion and Maintenance

A 12-year-old child enjoys collecting stamps, playing soccer, and participating in Boy Scout

activities. The nurse recognizes that the child is displaying which developmental task?

a. Identity

b. Industry

c. Integrity

d. Intimacy

ANS: B

Industry is engaging in tasks that can be carried through to completion, learning to compete

and cooperate with others, and learning rules. Industry is the developmental task characteristic

of the school-age child. Identity is the developmental task of adolescence. Integrity and

intimacy are not developmental tasks of childhood.

PTS: 1 DIF: Cognitive Level: Understand REF: 72

TOP: Integrated Process: Nursing Process: Assessment

MSC: Area of Client Needs: Health Promotion and Maintenance

A nurse is conducting parenting classes for parents of children ranging in ages 2 to 7 years.

The parents understand the term egocentrism when they indicate it means:

a. selfishness.

b. self-centeredness.

c. preferring to play alone.

d. unable to put self in another’s place.

ANS: D

According to Piaget, children ages 2 to 7 years are in the preoperational stage of development.

Children interpret objects and events not in terms of their general properties but in terms of

their relationships or their use to them. This egocentrism does not allow children of this age to

put themselves in another’s place. Selfishness, self-centeredness, and preferring to play alone

do not describe the concept of egocentricity.

PTS: 1 DIF: Cognitive Level: Apply REF: 73

TOP: Integrated Process: Nursing Process: Evaluation

MSC: Area of Client Needs: Health Promotion and Maintenance15. 16. 17. The nurse is observing parents playing with their 10-month-old child. Which should the nurse

recognize as evidence that the child is developing object permanence?

a. b. c. d. Looks for the toy that parents hide under the blanket

Returns the blocks to the same spot on the table

Recognizes that a ball of clay is the same when flattened out

Bangs two cubes held in her hands

ANS: A

Object permanence is the realization that items that leave the visual field still exist. When the

infant searches for the toy under the blanket, it is an indication that object permanence has

developed. Returning the blocks to the same spot on the table is not an example of object

permanence. Recognizing that a ball of clay is the same when flattened out is an example of

conservation, which occurs during the concrete operations stage from 7 to 11 years. Banging

two cubes together is a simple repetitive activity characteristic of developing a sense of cause

and effect.

PTS: 1 DIF: Cognitive Level: Apply REF: 73

TOP: Integrated Process: Nursing Process: Assessment

MSC: Area of Client Needs: Health Promotion and Maintenance

A father tells the nurse that his child is “filling up the house with collections” like seashells,

bottle caps, baseball cards, and pennies. The nurse should recognize that the child is

developing:

a. object permanence.

b. preoperational thinking.

c. concrete operational thinking.

d. ability to use abstract symbols.

ANS: C

During concrete operations, children develop logical thought processes. They are able to

classify, sort, order, and otherwise organize facts about the world. This ability fosters the

child’s ability to create collections. Object permanence is the realization that items that leave

the visual field still exist. This is a task of infancy and does not contribute to collections.

Preoperational thinking is concrete and tangible. Children in this age group cannot reason

beyond the observable, and they lack the ability to make deductions or generalizations.

Collections are not typical for this developmental level. The ability to use abstract symbols is

a characteristic of formal operations, which develops during adolescence. These children can

develop and test hypotheses.

PTS: 1 DIF: Cognitive Level: Understand REF: 73

TOP: Integrated Process: Teaching/Learning

MSC: Area of Client Needs: Health Promotion and Maintenance

A visitor arrives at a daycare center during lunch time. The preschool children think that every

time they have lunch a visitor will arrive. Which preoperational characteristic is being

displayed?

a. Egocentrism

b. Transductive reasoning

c. Intuitive reasoning

d. Conservation

ANS: B18. 19. Transductive reasoning is when two events occur together, they cause each other. The

expectation that every time lunch is served a visitor will arrive is descriptive of transductive

reasoning. Egocentrism is the inability to see things from any perspective than their own.

Intuitive reasoning (e.g., the stars have to go to bed just as they do) is predominantly

egocentric thought. Conservation (able to realize that physical factors such as volume, weight,

and number remain the same even though outward appearances are changed) does not occur

until school age.

PTS: 1 DIF: Cognitive Level: Analyze REF: 73

TOP: Integrated Process: Nursing Process: Diagnosis

MSC: Area of Client Needs: Health Promotion and Maintenance

Which behavior is most characteristic of the concrete operations stage of cognitive

development?

a. b. c. d. Progression from reflex activity to imitative behavior

Inability to put oneself in another’s place

Increasingly logical and coherent thought processes

Ability to think in abstract terms and draw logical conclusions

ANS: C

During the concrete operations stage of development, which occurs approximately between

ages 7 and 11 years, increasingly logical and coherent thought processes occur. This is

characterized by the child’s ability to classify, sort, order, and organize facts to use in problem

solving. The progression from reflex activity to imitative behavior is characteristic of the

sensorimotor stage of development. The inability to put oneself in another’s place is

characteristic of the preoperational stage of development. The ability to think in abstract terms

and draw logical conclusions is characteristic of the formal operations stage of development.

PTS: 1 DIF: Cognitive Level: Understand REF: 73

TOP: Integrated Process: Nursing Process: Assessment

MSC: Area of Client Needs: Health Promotion and Maintenance

According to Kohlberg, children develop moral reasoning as they mature. Which statement is

most characteristic of a preschooler’s stage of moral development?

a. b. c. d. Obeying the rules of correct behavior is important.

Showing respect for authority is important behavior.

Behavior that pleases others is considered good.

Actions are determined as good or bad in terms of their consequences.

ANS: D

Preschoolers are most likely to exhibit characteristics of Kohlberg’s preconventional level of

moral development. During this stage, they are culturally oriented to labels of good or bad,

right or wrong. Children integrate these concepts based on the physical or pleasurable

consequences of their actions. Obeying the rules of correct behavior, showing respect for

authority, and engaging in behavior that pleases others are characteristics of Kohlberg’s

conventional level of moral development.

PTS: 1 DIF: Cognitive Level: Understand REF: 73

TOP: Integrated Process: Nursing Process: Planning

MSC: Area of Client Needs: Health Promotion and Maintenance20. 21. 22. A school nurse notes that school-age children generally obey the rules at school. The nurse

recognizes that the children are displaying which stage of moral development?

a. Preconventional

b. Conventional

c. Post-conventional

d. Undifferentiated

ANS: B

Conventional stage of moral development is described as obeying the rules, doing one’s duty,

showing respect for authority, and maintaining the social order. This stage is characteristic of

school-age children’s behavior. The preconventional stage is characteristic of the toddler and

preschool age. At this stage, the child has no concept of the basic moral order that supports

being good or bad. The post-conventional level is characteristic of an adolescent and occurs at

the formal stage of operation. Undifferentiated describes an infant’s understanding of moral

development.

PTS: 1 DIF: Cognitive Level: Analyze REF: 73-74

TOP: Integrated Process: Nursing Process: Evaluation

MSC: Area of Client Needs: Health Promotion and Maintenance

A nurse observes a toddler playing with sand and water. The nurse appropriately documents

this type of play as _____ play.

a. skill

b. dramatic

c. social-affective

d. sense-pleasure

ANS: D

The toddler playing with sand and water is engaging in sense-pleasure play. This is

characterized by nonsocial situations in which the child is stimulated by objects in the

environment. Infants engage in skill play when they persistently demonstrate and exercise

newly acquired abilities. Dramatic play is the predominant form of play in the preschool

period. Children pretend and fantasize. Social-affective play is one of the first types of play in

which infants engage. The infant responds to interactions with people.

PTS: 1 DIF: Cognitive Level: Apply REF: 75

TOP: Integrated Process: Communication and Documentation

MSC: Area of Client Needs: Health Promotion and Maintenance

In which type of play are children engaged in similar or identical activity, without

organization, division of labor, or mutual goal?

a. Solitary

b. Parallel

c. Associative

d. Cooperative

ANS: C23. 24. 25. In associative play, no group goal is present. Each child acts according to his or her own

wishes. Although the children may be involved in similar activities, no organization, division

of labor, leadership assignment, or mutual goal exists. Solitary play describes children playing

alone with toys different from those used by other children in the same area. Parallel play

describes children playing independently but being among other children. Cooperative play is

organized. Children play in a group with other children who play in activities for a common

goal.

PTS: 1 DIF: Cognitive Level: Understand REF: 76

TOP: Integrated Process: Nursing Process: Assessment

MSC: Area of Client Needs: Health Promotion and Maintenance

The nurse observes some children in the playroom. Which play situation exhibits the

characteristics of parallel play?

a. b. c. d. Kimberly and Amanda sharing clay to each make things

Brian playing with his truck next to Kristina playing with her truck

Adam playing a board game with Kyle, Steven, and Erich

Danielle playing with a music box on her mother’s lap

ANS: B

Playing with trucks next to each other but not together is an example of parallel play. Both

children are engaged in similar activities in proximity to each other; however, they are each

engaged in their own play. Sharing clay to make things is characteristic of associative play.

Friends playing a board game together is characteristic of cooperative play. A child playing

with something by herself on her mother’s lap is an example of solitary play.

PTS: 1 DIF: Cognitive Level: Analyze REF: 76

TOP: Integrated Process: Nursing Process: Assessment

MSC: Area of Client Needs: Health Promotion and Maintenance

A nurse is planning play activities for school-age children. Which type of a play activity

should the nurse plan?

a. Solitary

b. Parallel

c. Associative

d. Cooperative

ANS: D

School-age children engage in cooperative play where it is organized and interactive. Playing

a game is a good example of cooperative play. Solitary play is appropriate for infants, parallel

play is an activity appropriate for toddlers, and associative play is an activity appropriate for

preschool-age children.

PTS: 1 DIF: Cognitive Level: Apply REF: 77

TOP: Integrated Process: Nursing Process: Planning

MSC: Area of Client Needs: Health Promotion and Maintenance

Which following function of play is a major component of play at all ages?

a. Creativity

b. Socialization

c. Intellectual development26. 27. 28. d. Sensorimotor activity

ANS: D

Sensorimotor activity is a major component of play at all ages. Active play is essential for

muscle development and allows the release of surplus energy. Through sensorimotor play,

children explore their physical world by using tactile, auditory, visual, and kinesthetic

stimulation. Creativity, socialization, and intellectual development are each functions of play

that are major components at different ages.

PTS: 1 DIF: Cognitive Level: Understand REF: 77

TOP: Integrated Process: Nursing Process: Assessment

MSC: Area of Client Needs: Health Promotion and Maintenance: Developmental Stages and

Transitions

Parents are asking the clinic nurse about an appropriate toy for their toddler. Which response

by the nurse is appropriate?

a. b. c. d. “Your child would enjoy playing a board game.”

“A toy your child can push or pull would help develop muscles.”

“An action figure toy would be a good choice.”

“A 25-piece puzzle would help your child develop recognition of shapes.”

ANS: B

Toys should be appropriate for the child’s age. A toddler would benefit from a toy he or she

could push or pull. The child is too young for a board game, action figure, or 25-piece puzzle.

PTS: 1 DIF: Cognitive Level: Apply REF: 78

TOP: Integrated Process: Teaching/Learning

MSC: Area of Client Needs: Health Promotion and Maintenance

Which is probably the single most important influence on growth at all stages of

development?

a. Nutrition

b. Heredity

c. Culture

d. Environment

ANS: A

Nutrition is the single most important influence on growth. Dietary factors regulate growth at

all stages of development, and their effects are exerted in numerous and complex ways.

Adequate nutrition is closely related to good health throughout life. Heredity, culture, and

environment contribute to the child’s growth and development. However, good nutrition is

essential throughout the life span for optimal health.

PTS: 1 DIF: Cognitive Level: Understand REF: 69

TOP: Integrated Process: Nursing Process: Planning

MSC: Area of Client Needs: Health Promotion and Maintenance

A nurse is counseling an adolescent, in her second month of pregnancy, about the risk of

teratogens. The adolescent has understood the teaching if she makes which statement?

a. b. c. “I will be able to continue taking isotretinoin (Accutane) for my acne.”

“I can continue to clean my cat’s litter box.”

“I should avoid any alcoholic beverages.”29. 30. d. “I will ask my physician to adjust my phenytoin (Dilantin) dosage.”

ANS: C

Teratogens are agents that cause birth defects when present in the prenatal period. Avoidance

of alcoholic beverages is recommended to prevent fetal alcohol syndrome. Isotretinoin

(Accutane) and phenytoin (Dilantin) have been shown to have teratogenic effects and should

not be taken during pregnancy. Cytomegalovirus, an infection agent and a teratogen, can be

transmitted through cat feces, and cleaning the litter box during pregnancy should be avoided.

PTS: 1 DIF: Cognitive Level: Analyze REF: 81

TOP: Integrated Process: Teaching/Learning

MSC: Area of Client Needs: Health Promotion and Maintenance

What should the nurse consider when discussing language development with parents of

toddlers?

a. b. c. d. Sentences by toddlers include adverbs and adjectives.

The toddler expresses himself or herself with verbs or combination words.

The toddler uses simple sentences.

Pronouns are used frequently by the toddler.

ANS: B

The first parts of speech used are nouns, sometimes verbs (e.g., “go”), and combination words

(e.g., “bye-bye”). Responses are usually structurally incomplete during the toddler period. The

preschool child begins to use adjectives and adverbs to qualify nouns followed by adverbs to

qualify nouns and verbs. Pronouns are not added until the later preschool years. By the time

children enter school, they are able to use simple, structurally complete sentences that average

five to seven words.

PTS: 1 DIF: Cognitive Level: Apply REF: 73

TOP: Integrated Process: Teaching/Learning

MSC: Area of Client Needs: Health Promotion and Maintenance

A nurse is observing children at play. Which figure depicts associative play?

a. c.

b. d.

ANS: CThe children depicted in the figure at the carnival ride are demonstrating associative play.

They are engaged in similar or identical activities. The child depicted playing alone is

demonstrating solitary play. The children playing on the beach depict parallel play. They are

playing side by side but are participating in different activities. The children depicted playing

a board game are engaging in cooperative play.

PTS: 1 DIF: Cognitive Level: Analyze REF: 76-77

TOP: Integrated Process: Nursing Process: Evaluation

MSC: Area of Client Needs: Health Promotion and Maintenance

MULTIPLE RESPONSE

1. 2. Play serves many purposes. In teaching parents about appropriate activities, the nurse should

inform them that play serves which of the following function? (Select all that apply.)

a. Intellectual development

b. Physical development

c. Socialization

d. Creativity

e. Temperament development

ANS: A, C, D

A common statement is that play is the work of childhood. Intellectual development is

enhanced through the manipulation and exploration of objects. Socialization is encouraged by

interpersonal activities and learning of social roles. In addition, creativity is developed

through the experimentation characteristic of imaginative play. Physical development depends

on many factors; play is not one of them. Temperament refers to behavioral tendencies that are

observable from the time of birth. The actual behaviors, but not the child’s temperament

attributes, may be modified through play.

PTS: 1 DIF: Cognitive Level: Understand REF: 77

TOP: Integrated Process: Nursing Process: Assessment

MSC: Area of Client Needs: Health Promotion and Maintenance

What factors indicate parents should seek genetic counseling for their child? (Select all that

apply.)

a. Abnormal newborn screen

b. Family history of a hereditary disease

c. History of hypertension in the family

d. Severe colic as an infant

e. Metabolic disorder

ANS: A, B, E

Factors that are indicative parents should seek genetic counseling for their child include an

abnormal newborn screen, family history of a hereditary disease, and a metabolic disorder. A

history of hypertension or severe colic as an infant is not an indicator of a genetic disease.

PTS: 1 DIF: Cognitive Level: Understand REF: 82

TOP: Integrated Process: Nursing Process: Assessment

MSC: Area of Client Needs: Health Promotion and Maintenance3. A nurse is preparing to administer a Denver II. Which is a correct statement about the Denver

II? (Select all that apply.)

a. b. c. d. e. All items intersected by the age line should be administered.

There is no correction for a child born prematurely.

The tool is an intelligence test.

Toddlers and preschoolers should be prepared by presenting the test as a game.

Presentation of the toys from the kit should be done one at a time.

ANS: A, D, E

To identify “cautions,” all items intersected by the age line are administered. Toddlers and

preschoolers should be tested by presenting the Denver II as a game. Because children are

easily distracted, perform each item quickly and present only one toy from the kit at a time.

Before beginning the screening, ask whether the child was born preterm and correctly

calculate the adjusted age. Up to 24 months of age, allowances are made for preterm infants

by subtracting the number of weeks of missed gestation from their present age and testing

them at the adjusted age. Explain to the parents and child, if appropriate, that the screenings

are not intelligence tests but rather are a method of showing what the child can do at a

particular age.

PTS: 1 DIF: Cognitive Level: Apply REF: 79

TOP: Integrated Process: Nursing Process: Implementation

MSC: Area of Client Needs: Health Promotion and Maintenance

COMPLETION

1. The nurse is recording a normal interpretation of a Denver II assessment. The nurse

understands that the maximum number of cautions determined for a normal interpretation is

_____. (Record your answer in a whole number.)

ANS:

1

Interpretation of normal for a Denver II is no delays and a maximum of one caution.

PTS: 1 DIF: Cognitive Level: Apply REF: 79

TOP: Integrated Process: Nursing Process: Implementation

MSC: Area of Client Needs: Health Promotion and Maintenance

ESSAY

1. Place in order the sequence of cephalocaudal development that the nurse expects to find in the

infant. Begin with the first development expected, sequencing to the final. Provide answer

using lowercase letters separated by commas (e.g., a, b, c, d).

a. Crawl

b. Sit unsupported

c. Lift head when prone

d. Gain complete head control

e. Walk

ANS:c, d, b, a, e

Cephalocaudal development is head-to-tail. Infants achieve structural control of the head

before they have control of their trunks and extremities, they lift their head while prone,

obtain complete head control, sit unsupported, crawl, and walk sequentially.

PTS: 1 DIF: Cognitive Level: Apply REF: 65

TOP: Integrated Process: Nursing Process: Implementation

MSC: Area of Client Needs: Health Promotion and Maintenance