The nurse is assessing an adult patient for the presence of Piaget's formal operations stage of development. What assessment question should the nurse ask the patient? • ìHow do you usually go about making difficult decisions?î • ìDo you consider yourself to be an intelligent person?î • ìHow would you describe your relationship with authority figures?î • ìIn relationships, do you consider yourself to be a 'giver' or a 'taker'?î • The nurse has observed that a patient adheres rigidly to the norms of her family and her culture. In the context of Freud's theory of development, this pattern of behavior is attributable to the action of what component of personality? • The id • The ego • The superego • The identity • A school nurse is working with kindergarten students. Within Kohlberg's framework of moral development, the nurse should recognize that these students' moral reasoning is primarily motivated by which of the following? • An innate conscience • Fear of the negative consequences of individual actions • Motivation to exhibit behaviors that are culturally normalized • Adherence to basic moral beliefs • The school nurse has learned that a 14-year-old student is having social difficulties. According to Erikson, what is the most likely source of this child's stress? • The student is experiencing moral dilemmas. • The student is having difficulty creating an identity. • The student is experiencing a sexual crisis. • The student having difficulty understanding the viewpoints of others.A nurse has completed the general survey of a patient who has been transferred to the unit. The information gathered during the general survey primarily provides the nurse with which of the following? Select all that apply. • An indication of the level of physical distress experienced by the patient • Clues about the overall health of the patient • A direct link to the patient's medical diagnosis • Indications about normal variations in the status of body systems • Data relating to the patient's level of social support • A nurse is preparing to assess an adult patient's body temperature. At which time of the day would the nurse expect to obtain the lowest body temperature? • Early morning • Early afternoon • Late afternoon • Late evening • The nurse is preparing to assess a patient's vital signs. Which vital sign should the nurse assess first? • Temperature • Pulse • Respiration • Blood pressure • A nurse is reviewing a colleague's documentation of a patient assessment. The nurse reads that the patient's radial pulse was 2+. How should the nurse interpret this assessment finding? • The patient's radial pulse occluded easily. • The patient's radial pulse occluded with moderate pressure. • The patient's radial pulse occluded with very firm pressure. • The patient's radial pulse could not be manually occluded. • The nurse is conducting an assessment of an older adult patient who has a diagnosis of chronic heart failure. How can the nurse best assess the effects of the patient's stroke volume? • Take the blood pressure while the patient is standing. • Measure the strength of the radial pulse. • Add the radial pulse and the systolic blood pressure. • Calculate the difference between the diastolic and systolic pressures. • A nurse obtains the blood pressure of a patient who is uncharacteristically fatigued and who is lying in bed rather than sitting in a chair. The nurse should interpret the patient's blood pressure reading in light of what principle? • The patient's blood pressure will be slightly highly than the patient's norm. • Position rarely affects the patient's blood pressure. • The patient's blood pressure will be slightly lower than standing readings. • There will be questionable accuracy of the blood pressure reading. • The nurse is completing an initial assessment of a patient who is new to the ambulatory clinic. Before assessing the patient's blood pressure, a nurse asks him what his usual blood pressure is. The nurse bases this action primarily on what rationale? • It provides identifiable data about the patient. • It verifies the patient's cardiac function. • It assesses the patient's distant memory recall. • It indicates the patient's involvement in his health care. • The nurse has begun a patient's assessment and is applying the blood pressure cuff on a patient's arm. Which action would be most appropriate? • The cuff is wrapped loosely around the arm. • The cuff is placed about 1 inch above the antecubital area. • The bladder inside the cuff encircles 50% of the arm circumference. • The nurse can fit three to four fingers under the inflated cuff. • Which of the following would be most important for the nurse to do when assessing a patient's blood pressure? • Palpate the pulsations of the ulnar artery. • Hold the patient's arm slightly flexed with palm down. • Inflate the cuff 30 mm Hg above where the radial pulse disappears. • Deflate the cuff about 5 mm Hg per second. • The nurse is auscultating a patient's blood pressure and identifies the portion of the blood pressure cycle reflecting the break in sounds occurring between the first and second sounds. This is known as which of the following? • Auscultatory gap • Korotkoff sounds • Phase V • Diastolic value • When assessing an older adult patient with osteoporotic thinning and vertebral collapse, which of the following findings would the nurse expect to identify? • Lordosis • Increased arm swing • Narrowed gait • Kyphosis • A nurse observes the posture of a male patient and finds him leaning forward and bracing himself while sitting on the exam table. Which of the following would the nurse most likely suspect? • Chronic obstructive pulmonary disease • Neurological deficit • Metabolic disorder • Vestibular disorder • The nurse is completing the general survey of a patient and determines that the patient's temperature is 102∞F. Which of the following would the nurse also expect to find? • Weak, thready pulse • Heart rate greater than 100 bpm • Respiratory rate between 12 and 20 breaths/minute • Diastolic blood pressure 10 mm Hg greater than normal • The nurse is completing the assessment of a patient who takes a beta-adrenergic blocker and a diuretic. Which assessment would be most important for the nurse to complete to ensure safety with a patient receiving antihypertensive agents? • Noting a widened pulse pressure • Asking whether the patient is experiencing headaches • Assessing for a rise in blood pressure when standing • Evaluating for orthostatic hypotension • A nurse is obtaining a patient's radial pulse. Which of the following actions demonstrates correct technique for this assessment? • Application of firm pressure on the wrist area along the side of the fifth digit • Use of two middle fingers lightly applied to wrist area along the thumb side • Use of the thumb and index finger applied to obliterate the wrist area along the thumb side • Application of the bell of the stethoscope to the antecubital area of the upper extremity • The nurse is assessing the skin condition and color of an African-American patient. Which of the following would the nurse document as an abnormal finding? • Evenly distributed color • Light to medium dark brown skin • Ashen gray skin color • Lack of visible pores • The nurse is admitting a patient to surgical daycare and is assessing the patient's vital signs. When obtaining the patient's oral temperature, where should the nurse insert the thermometer? • At the gum line between the check and tongue • Deep in the posterior sublingual pocket • On either side of the frenulum at gingival level • Just past the teeth, below the tongue • An older adult patient has been admitted to the medical unit after suffering an exacerbation of chronic obstructive pulmonary disease (COPD). Which of the following should the nurse do to assess the depth of the patient's respirations? • Count the respirations for 30 seconds and multiply by 2. • Place the patient's arm across the chest while palpating the pulse. • Observe the patient's chest expansion bilaterally. • Percuss the patient's posterior thorax • Due to a change in the patient's level of consciousness, a nurse is now assessing a patient's temperature by the axillary route. Previously, the patient had an oral temperature of 98.4∫F. Which finding would the nurse interpret as corresponding most closely to the patient's previous temperature? • 97.0∫F • 97.4∫F • 98.9∫F • 99.4∫F • A nurse in the surgical daycare department has called a patient in from the waiting room and is meeting the patient for the first time. The nurse immediately observes that the patient has a noticeably ìstoopedî posture. How should the nurse best follow up this abnormal assessment finding? • Facilitate a referral to the hospital's rheumatology department • Perform a focused assessment of the patient's musculoskeletal system • Obtained a detailed family health history from the patient • Document the assessment finding and inform the anesthesiologist • A nurse is completing a general survey of a patient's health and is beginning by measuring the patient's vital signs. What assessment question constitutes the ìfifth vital signî? • ìCan you tell me the date and month?î • ìCan I check your oxygen saturation level?î • ìAre you experiencing any shortness of breath?î • ìAre you having any pain right now?î • An 84-year-old man has been admitted to the emergency department from an extended care facility. Facility staff suspect that the patient has pneumonia, and his malaise, productive cough, shortness of breath, and adventitious breath sounds are consistent with this diagnosis. However, the nurse's assessment of the patient's vital signs yields an oral temperature of 97.5∞F. How should the nurse best interpret this assessment finding? • The patient likely has a cardiac health problem, not a respiratory health problem. • The patient's signs and symptoms are related to hypothermia rather than infection. • The patient's normothermic temperature does not rule out the presence of an infection. • The patient's infection is no longer localized and has become systemic. • The nurse is performing an assessment of a hospital patient at the beginning of a shift. When assessing the patient's heart rate, the nurse will most likely palpate what artery? • Femoral artery • Aorta • Ulnar artery • Radial artery