Nursing NURS258 Final Exam – Comprehensive Study Guide Practice Questions and Key
Concepts Review
Order of physical assessment skills - correct answer ✔✔inspection, palpation, (percussion),
auscultation
Frequency of VS - correct answer ✔✔MD orders, critical situations, after surgery, during blood
transfusions, changes in pt status
Factors that affect temperature - correct answer ✔✔age, exercise, hormone changes, circadian
rhythm, stress, environment, illness and injury
Apical pulse location - correct answer ✔✔5th intercostal space, left mid-clavicular line
Why might you take an apical pulse? - correct answer ✔✔most accurate and when pt is on
cardiac meds
Factors the influence pulse - correct answer ✔✔exercise, temperature, emotions, meds,
hemorrhage, postural changes
Factors affecting respirations - correct answer ✔✔exercise, acute pain, anxiety, smoking, body
position, medications, neurological injury, hemoglobin function
Alterations in breathing pattern - correct answer ✔✔bradypnea, tachypnea, hyperpnea, apnea,
hyperventilation, hypoventilation
Factors affecting BP - correct answer ✔✔age, stress, ethnicity (AA men higher BP), meds,
activity, weight, smoking
,How much change in BP would indicate orthostatic hypotension? - correct answer ✔✔drop in
20 mmHg systolic
How would you estimate systolic BP? - correct answer ✔✔1. palpate radial pulse
2. inflate cuff until pulse disappears
3. deflate cuff slowly
4. record mmHg where pulse reappears
When should the nurse start checking BP on children? - correct answer ✔✔not until at least 3
years old
When assessing children specifically for mental status what area's should the nurse check? -
correct answer ✔✔head control, motor development, sensory development (7-9 months fully
developed), Babinski reflex (children fan toes, adults flex feet and toes)
LOC: alert - correct answer ✔✔Awake or readily aroused, oriented, fully aware of external and
internal stimuli and responds appropriately
LOC: lethargic - correct answer ✔✔not fully alert, drifts off to sleep easily, can be aroused to
name but is drowsy, responses seem slow and fuzzy, spontaneous movements are decreased
LOC: obtunded - correct answer ✔✔transitional state between lethargy and stupor, difficult to
arouse-needs loud shout or vigorous shakes, acts confused when is aroused, speech may be
mumbled and incoherent
LOC: stupor or semi-coma - correct answer ✔✔responds only to vigorous shaking or pain with
groans, may have appropriate motor response
LOC: coma - correct answer ✔✔completely unconscious, no response to pain or any external
, light coma = some reflex
deep coma = no motor response
LOC: delirium (Acute Confusional State) - correct answer ✔✔clouding of consciousness,
impaired alertness, inattentive, agitation, hallucinations, disoriented
mood vs affect - correct answer ✔✔mood is external expression of state of mind vs affect being
more internal prolonged display of feelings
Abstract reasoning - correct answer ✔✔pondering a deeper meaning beyond the concrete and
literal
Abstract reasoning involves 3 components - correct answer ✔✔though process, thought
content, preceptions
Thought process vs thought content - correct answer ✔✔thought process is the way person
thinks vs though content being what a person thinks
Perceptions definition (related to abstract reasoning) - correct answer ✔✔awareness of
environment though all 5 senses, this altered perceptions may result in hallucinations
What are the 4 areas of a mental status assessment? - correct answer ✔✔Appearance,
Behavior, Cognitive function, Thought process and perceptions
Olfactory nerve (smell, how to assess?) - correct answer ✔✔smell identification
Optic nerve (vision, how to assess?) - correct answer ✔✔snellen, color
Concepts Review
Order of physical assessment skills - correct answer ✔✔inspection, palpation, (percussion),
auscultation
Frequency of VS - correct answer ✔✔MD orders, critical situations, after surgery, during blood
transfusions, changes in pt status
Factors that affect temperature - correct answer ✔✔age, exercise, hormone changes, circadian
rhythm, stress, environment, illness and injury
Apical pulse location - correct answer ✔✔5th intercostal space, left mid-clavicular line
Why might you take an apical pulse? - correct answer ✔✔most accurate and when pt is on
cardiac meds
Factors the influence pulse - correct answer ✔✔exercise, temperature, emotions, meds,
hemorrhage, postural changes
Factors affecting respirations - correct answer ✔✔exercise, acute pain, anxiety, smoking, body
position, medications, neurological injury, hemoglobin function
Alterations in breathing pattern - correct answer ✔✔bradypnea, tachypnea, hyperpnea, apnea,
hyperventilation, hypoventilation
Factors affecting BP - correct answer ✔✔age, stress, ethnicity (AA men higher BP), meds,
activity, weight, smoking
,How much change in BP would indicate orthostatic hypotension? - correct answer ✔✔drop in
20 mmHg systolic
How would you estimate systolic BP? - correct answer ✔✔1. palpate radial pulse
2. inflate cuff until pulse disappears
3. deflate cuff slowly
4. record mmHg where pulse reappears
When should the nurse start checking BP on children? - correct answer ✔✔not until at least 3
years old
When assessing children specifically for mental status what area's should the nurse check? -
correct answer ✔✔head control, motor development, sensory development (7-9 months fully
developed), Babinski reflex (children fan toes, adults flex feet and toes)
LOC: alert - correct answer ✔✔Awake or readily aroused, oriented, fully aware of external and
internal stimuli and responds appropriately
LOC: lethargic - correct answer ✔✔not fully alert, drifts off to sleep easily, can be aroused to
name but is drowsy, responses seem slow and fuzzy, spontaneous movements are decreased
LOC: obtunded - correct answer ✔✔transitional state between lethargy and stupor, difficult to
arouse-needs loud shout or vigorous shakes, acts confused when is aroused, speech may be
mumbled and incoherent
LOC: stupor or semi-coma - correct answer ✔✔responds only to vigorous shaking or pain with
groans, may have appropriate motor response
LOC: coma - correct answer ✔✔completely unconscious, no response to pain or any external
, light coma = some reflex
deep coma = no motor response
LOC: delirium (Acute Confusional State) - correct answer ✔✔clouding of consciousness,
impaired alertness, inattentive, agitation, hallucinations, disoriented
mood vs affect - correct answer ✔✔mood is external expression of state of mind vs affect being
more internal prolonged display of feelings
Abstract reasoning - correct answer ✔✔pondering a deeper meaning beyond the concrete and
literal
Abstract reasoning involves 3 components - correct answer ✔✔though process, thought
content, preceptions
Thought process vs thought content - correct answer ✔✔thought process is the way person
thinks vs though content being what a person thinks
Perceptions definition (related to abstract reasoning) - correct answer ✔✔awareness of
environment though all 5 senses, this altered perceptions may result in hallucinations
What are the 4 areas of a mental status assessment? - correct answer ✔✔Appearance,
Behavior, Cognitive function, Thought process and perceptions
Olfactory nerve (smell, how to assess?) - correct answer ✔✔smell identification
Optic nerve (vision, how to assess?) - correct answer ✔✔snellen, color
