NURS 155 EXAM 3 QUESTIONS AND
ANSWERS WITH COMPLETE
SOLUTIONS 100% CORRECT RATED
A+ (GRADED A+)
Question: How are delirium, depression, and dementia clinically differentiated
from one another? Answer: ✔✔ These psychological and neurological states are
distinguished by the following clinical characteristics:
Delirium: An acute, fluctuating, and typically reversible state of cognitive
confusion, commonly precipitated by an underlying acute medical illness,
infection, or drug toxicity.
Depression: An affective mood disorder characterized by persistent feelings
of sadness, dejection, and a profound sense of hopelessness that interferes
with daily functioning.
Dementia: A progressive, permanent, and irreversible decline in intellectual
and cognitive functioning, marked by structural brain changes.
Question: What is hemiparesis, and how does a unilateral brain injury manifest
physically? Answer: ✔✔ Hemiparesis is defined as muscular weakness or partial
paralysis localized to one side of the body. Because of the decussation (crossing
over) of nerve fibers in the brainstem, neurological damage sustained in the right
hemisphere of the brain affects motor function on the left side of the body, and
vice versa.
Question: What are the major classifications of sensory deficits, along with
clinical examples of each? Answer: ✔✔ Sensory impairments are categorized
across the primary sensory modalities:
Tactile (Touch): Alterations in physical sensation, such as peripheral
neuropathy (numbness or tingling commonly seen in extremities).
Olfactory (Smell): A diminished or completely absent sense of smell,
known as anosmia.
Gustatory (Taste): A reduction in taste acuity, often caused by an age-
related loss of functional gustatory taste cells.
, Auditory (Hearing): Hearing impairment divided into conductive loss
(sound blocking in the outer/middle ear), sensorineural loss (inner ear/nerve
damage), or presbycusis (progressive, age-related hearing loss).
Equilibrium (Balance): Disruption of spatial orientation and balance,
frequently manifesting as motion sickness or Ménière's disease.
Visual (Vision): Sight impairments including myopia (nearsightedness),
presbyopia (age-related loss of near focusing), cataracts (clouding of the
crystalline lens), glaucoma (optic nerve damage from elevated intraocular
pressure), diabetic retinopathy (microvascular retinal damage), and macular
degeneration (loss of central vision).
Visual Pathologies: Cataracts vs. Healthy Eye. Source: ttsz / Getty Images
Question: What action must a clinician take during Range of Motion (ROM)
exercises if a patient reports discomfort or if structural resistance is encountered?
Answer: ✔✔ Range of motion exercises must be immediately discontinued. A
healthcare provider must never force, hyperextend, or flex a joint beyond its
natural resistance or the patient's absolute point of comfort.
page 560 safety practice alert
The nurse is preparing to provide wound care to a client with a stage 1 pressure
injury. Which dressing would the nurse expect to be prescribed in the treatment
of this wound?
1. Hydrogel dressing
2. Transparent dressing
3. Antimicrobial dressing
4. Calcium alginate dressing -ANSWER ✔✔2. Transparent dressing
A stage 1 pressure injury is characterized by intact
,skin with nonblanchable erythema. Dressings used to manage a stage 1 pressure
injury include transparent dressings, hydrocolloid dressings, or no dressing and
leaving the wound open to air. The wound should resolve without epidermal loss
over a period of 7 to 14 days. Hydrogel dressings are used to maintain a moist
environment for wound healing. Calcium alginate is absorbent and is used in stage
4 wounds or those with deeper tissue injury. Antimicrobial dressings are used for
pressure injuries that are infected.
Test-Taking Strategy: Focus on the subject, the wound dressing that is appropriate
in the treatment of a stage 1 pressure injury. Remember that dressing use is
conservative in this type of pressure injury, and includes the use of transparent
dressings or no dressing. The wound is expected to heal without epidermal loss
over a period of 7 to 14 days.
The nurse in a long-term care facility is observing a nursing student provide foot
care to a client with diabetes mellitus. Which action by the nursing student would
indicate a need for further teaching?
1. The nursing student tells the client to avoid soaking the feet.
2. The nursing student dries the feet thoroughly, including in between the toes.
3. The nursing student advises the client to consult the physician or a podiatrist
regarding nail trimming.
4. The nursing student applies lotion to the dorsal and plantar surfaces of the feet
and in between the toes. -ANSWER ✔✔4. The nursing student applies lotion to the
dorsal and plantar surfaces of the feet and in between the toes.
Clients with diabetes mellitus are at an increased
risk for impaired skin integrity related to peripheral neuropathy or vascular
insufficiency. The feet are at an increased risk for the development of wounds and
some clients may be unable to thoroughly inspect the feet regularly due to impaired
, mobility or other impairments. Meticulous foot care is necessary to prevent
complications. The client's feet would
not be soaked to prevent maceration, or skin softening, as this increases the risk of
infection. Regarding nail trimming, a podiatrist or a physician's order may be
necessary to trim the nails, as a client with diabetes mellitus is at increased risk for
infection if the skin were to be accidentally cut. The feet need to be dried
thoroughly, with special attention given to the areas between the toes, as skin
breakdown or ulcers can go undetected in this area. Lotion needs to be applied to
the dorsal and plantar surfaces of the foot. However, it would not be applied
between the toes as this area needs to be kept dry. Therefore, option 4 is the action
by the nursing student that requires a need for further teaching.
As the nurse, you are providing care for a client and notice tiny, pinpoint red or
purple spots. It would appropriate for you to document these spots as
A)mottling
B)petechiae
C)cyanosis
D)jaundice. -ANSWER ✔✔B) Petechiae
As they nurse, you are performing a physical assessment of a client and find an
area of bluish marbling. You should document this area as
A) flushing
B) mottling
C) ecchymosis
D) cyanosis. -ANSWER ✔✔C) Ecchymosis
Fibrin -ANSWER ✔✔connective tissue that deposits in injured area and becomes
framework for cell repair.
ANSWERS WITH COMPLETE
SOLUTIONS 100% CORRECT RATED
A+ (GRADED A+)
Question: How are delirium, depression, and dementia clinically differentiated
from one another? Answer: ✔✔ These psychological and neurological states are
distinguished by the following clinical characteristics:
Delirium: An acute, fluctuating, and typically reversible state of cognitive
confusion, commonly precipitated by an underlying acute medical illness,
infection, or drug toxicity.
Depression: An affective mood disorder characterized by persistent feelings
of sadness, dejection, and a profound sense of hopelessness that interferes
with daily functioning.
Dementia: A progressive, permanent, and irreversible decline in intellectual
and cognitive functioning, marked by structural brain changes.
Question: What is hemiparesis, and how does a unilateral brain injury manifest
physically? Answer: ✔✔ Hemiparesis is defined as muscular weakness or partial
paralysis localized to one side of the body. Because of the decussation (crossing
over) of nerve fibers in the brainstem, neurological damage sustained in the right
hemisphere of the brain affects motor function on the left side of the body, and
vice versa.
Question: What are the major classifications of sensory deficits, along with
clinical examples of each? Answer: ✔✔ Sensory impairments are categorized
across the primary sensory modalities:
Tactile (Touch): Alterations in physical sensation, such as peripheral
neuropathy (numbness or tingling commonly seen in extremities).
Olfactory (Smell): A diminished or completely absent sense of smell,
known as anosmia.
Gustatory (Taste): A reduction in taste acuity, often caused by an age-
related loss of functional gustatory taste cells.
, Auditory (Hearing): Hearing impairment divided into conductive loss
(sound blocking in the outer/middle ear), sensorineural loss (inner ear/nerve
damage), or presbycusis (progressive, age-related hearing loss).
Equilibrium (Balance): Disruption of spatial orientation and balance,
frequently manifesting as motion sickness or Ménière's disease.
Visual (Vision): Sight impairments including myopia (nearsightedness),
presbyopia (age-related loss of near focusing), cataracts (clouding of the
crystalline lens), glaucoma (optic nerve damage from elevated intraocular
pressure), diabetic retinopathy (microvascular retinal damage), and macular
degeneration (loss of central vision).
Visual Pathologies: Cataracts vs. Healthy Eye. Source: ttsz / Getty Images
Question: What action must a clinician take during Range of Motion (ROM)
exercises if a patient reports discomfort or if structural resistance is encountered?
Answer: ✔✔ Range of motion exercises must be immediately discontinued. A
healthcare provider must never force, hyperextend, or flex a joint beyond its
natural resistance or the patient's absolute point of comfort.
page 560 safety practice alert
The nurse is preparing to provide wound care to a client with a stage 1 pressure
injury. Which dressing would the nurse expect to be prescribed in the treatment
of this wound?
1. Hydrogel dressing
2. Transparent dressing
3. Antimicrobial dressing
4. Calcium alginate dressing -ANSWER ✔✔2. Transparent dressing
A stage 1 pressure injury is characterized by intact
,skin with nonblanchable erythema. Dressings used to manage a stage 1 pressure
injury include transparent dressings, hydrocolloid dressings, or no dressing and
leaving the wound open to air. The wound should resolve without epidermal loss
over a period of 7 to 14 days. Hydrogel dressings are used to maintain a moist
environment for wound healing. Calcium alginate is absorbent and is used in stage
4 wounds or those with deeper tissue injury. Antimicrobial dressings are used for
pressure injuries that are infected.
Test-Taking Strategy: Focus on the subject, the wound dressing that is appropriate
in the treatment of a stage 1 pressure injury. Remember that dressing use is
conservative in this type of pressure injury, and includes the use of transparent
dressings or no dressing. The wound is expected to heal without epidermal loss
over a period of 7 to 14 days.
The nurse in a long-term care facility is observing a nursing student provide foot
care to a client with diabetes mellitus. Which action by the nursing student would
indicate a need for further teaching?
1. The nursing student tells the client to avoid soaking the feet.
2. The nursing student dries the feet thoroughly, including in between the toes.
3. The nursing student advises the client to consult the physician or a podiatrist
regarding nail trimming.
4. The nursing student applies lotion to the dorsal and plantar surfaces of the feet
and in between the toes. -ANSWER ✔✔4. The nursing student applies lotion to the
dorsal and plantar surfaces of the feet and in between the toes.
Clients with diabetes mellitus are at an increased
risk for impaired skin integrity related to peripheral neuropathy or vascular
insufficiency. The feet are at an increased risk for the development of wounds and
some clients may be unable to thoroughly inspect the feet regularly due to impaired
, mobility or other impairments. Meticulous foot care is necessary to prevent
complications. The client's feet would
not be soaked to prevent maceration, or skin softening, as this increases the risk of
infection. Regarding nail trimming, a podiatrist or a physician's order may be
necessary to trim the nails, as a client with diabetes mellitus is at increased risk for
infection if the skin were to be accidentally cut. The feet need to be dried
thoroughly, with special attention given to the areas between the toes, as skin
breakdown or ulcers can go undetected in this area. Lotion needs to be applied to
the dorsal and plantar surfaces of the foot. However, it would not be applied
between the toes as this area needs to be kept dry. Therefore, option 4 is the action
by the nursing student that requires a need for further teaching.
As the nurse, you are providing care for a client and notice tiny, pinpoint red or
purple spots. It would appropriate for you to document these spots as
A)mottling
B)petechiae
C)cyanosis
D)jaundice. -ANSWER ✔✔B) Petechiae
As they nurse, you are performing a physical assessment of a client and find an
area of bluish marbling. You should document this area as
A) flushing
B) mottling
C) ecchymosis
D) cyanosis. -ANSWER ✔✔C) Ecchymosis
Fibrin -ANSWER ✔✔connective tissue that deposits in injured area and becomes
framework for cell repair.
