NUR 112-FINAL EXAM WITH CORRECT
ANSWERS
Order of abdominal assessment - ANSWER-1. observe
2. inspect
3. auscultate
4. palpate
normal for cranial nerves 3,4,6 - ANSWER-EYE MOVEMENT
3 (M-Oculomotor) movement up, down, medial
4(M-Trochlear) looking down
6(M-Abducens) looking side to side
Urine Flow - ANSWER-kidneys, ureters, bladder, urethra, urethral meatus
A patient has a catheter after surgery. Why? What does anesthesia do to the
bladder - ANSWER-it silences the urge to urine
Types of incontinence - ANSWER-overflow, stress, urge, mixed
When palpating a patients bladder, you notice that it is firm. What do you do
next? - ANSWER-Ask the patient the last time they voided and how much.
Next, bladder scan
If a patient is incontinent, what will their skin look like - ANSWER-Skin will
look irritated, red, with ulcers
,stress incontinence - ANSWER-the inability to control the voiding of urine
under physical stress such as running, sneezing, laughing, or coughing
Top priorities of catheter - ANSWER-clean catheter every 12 hours, hang on
bed frame and below the bladder, should be emptied at half full
Structure of large intestine in order - ANSWER-Cecum-> Ascending colon->
Transverse-> Descending colon-> Sigmoid-> Rectum
What does black tarry stool indicate - ANSWER-upper GI bleed, or too much
iron
Bowel training - ANSWER-Daily routine. Assessing a normal pattern and
record of incontinent times. Helping to toilet at certain times of the day
If you notice blood in ileostomy, what to do next? - ANSWER-report
immediately
When giving a Kayexalate enema, what should you check - ANSWER-K level
Report all _____ occult stool - ANSWER-positive
What do you put on an incontinence patient - ANSWER-barrier cream
What is the top priority for a patient that has C.Diff? - ANSWER-Washing your
hands
What does a Guaiac/occult blood test show - ANSWER-If there is any GI
bleeding. You must have 3 positive test results to indicate actual GI bleed
,What can opioids do to bowel movements - ANSWER-may cause
constipation
How to check reflexes on an infant - ANSWER-rooting, moro, and tonic neck
reflex
plantar and palmar grasp
neuro assessment - ANSWER--perform hand hygiene
-introduce yourself
-identify patient with 2 identifiers
-asses pain level, allergies, and consciousness
-evaluate speech and comprehension
-test function of cranial nerves
-place hand on patients shoulders, while he/she shrugs against resistance
have them to squeeze two fingers
-feet resistance
-observe gait test
-Rhomberg test
-perform hand hygiene
document
How to palpate TMJ - ANSWER-Pads of first 2 fingers in front of the tragi of
each ear with mouth open and closed
What position should you lie patient for enema - ANSWER-Left sims' position
, When patient states they are in pain, how and when do you asses pain level
- ANSWER-Ask the patient to rate their pain level on a scale of 1 to 10
after inspecting the abdomen what should be done next - ANSWER-
auscultate
What is a normal Romberg test - ANSWER-Patient standing with feet
together, arms resting at the sides, eyes opening/closing
Cranial Nerve 2: Optic - ANSWER-sensory, vision
Cranial Nerve 3: Oculomotor - ANSWER-M; up, down, medial eye muscle
movements and papillary constriction
Cranial Nerve 4: Trochlear - ANSWER-M; down and medial eye muscle
movement
Cranial Nerve 6: Abducens - ANSWER-M: lateral eye movement
Cranial Nerve 7: Facial - ANSWER-Both: sensory- anterior 2/3 taste of tongue
motor- facial muscle movement
Cranial Nerve 8: Vestibulocochlear - ANSWER-S:hearing and balance
Cranial Nerve 11: Accessory - ANSWER-M; shoulder movement and head
rotation
Cranial Nerve 12: Hypoglossal - ANSWER-M: movement of tongue
ANSWERS
Order of abdominal assessment - ANSWER-1. observe
2. inspect
3. auscultate
4. palpate
normal for cranial nerves 3,4,6 - ANSWER-EYE MOVEMENT
3 (M-Oculomotor) movement up, down, medial
4(M-Trochlear) looking down
6(M-Abducens) looking side to side
Urine Flow - ANSWER-kidneys, ureters, bladder, urethra, urethral meatus
A patient has a catheter after surgery. Why? What does anesthesia do to the
bladder - ANSWER-it silences the urge to urine
Types of incontinence - ANSWER-overflow, stress, urge, mixed
When palpating a patients bladder, you notice that it is firm. What do you do
next? - ANSWER-Ask the patient the last time they voided and how much.
Next, bladder scan
If a patient is incontinent, what will their skin look like - ANSWER-Skin will
look irritated, red, with ulcers
,stress incontinence - ANSWER-the inability to control the voiding of urine
under physical stress such as running, sneezing, laughing, or coughing
Top priorities of catheter - ANSWER-clean catheter every 12 hours, hang on
bed frame and below the bladder, should be emptied at half full
Structure of large intestine in order - ANSWER-Cecum-> Ascending colon->
Transverse-> Descending colon-> Sigmoid-> Rectum
What does black tarry stool indicate - ANSWER-upper GI bleed, or too much
iron
Bowel training - ANSWER-Daily routine. Assessing a normal pattern and
record of incontinent times. Helping to toilet at certain times of the day
If you notice blood in ileostomy, what to do next? - ANSWER-report
immediately
When giving a Kayexalate enema, what should you check - ANSWER-K level
Report all _____ occult stool - ANSWER-positive
What do you put on an incontinence patient - ANSWER-barrier cream
What is the top priority for a patient that has C.Diff? - ANSWER-Washing your
hands
What does a Guaiac/occult blood test show - ANSWER-If there is any GI
bleeding. You must have 3 positive test results to indicate actual GI bleed
,What can opioids do to bowel movements - ANSWER-may cause
constipation
How to check reflexes on an infant - ANSWER-rooting, moro, and tonic neck
reflex
plantar and palmar grasp
neuro assessment - ANSWER--perform hand hygiene
-introduce yourself
-identify patient with 2 identifiers
-asses pain level, allergies, and consciousness
-evaluate speech and comprehension
-test function of cranial nerves
-place hand on patients shoulders, while he/she shrugs against resistance
have them to squeeze two fingers
-feet resistance
-observe gait test
-Rhomberg test
-perform hand hygiene
document
How to palpate TMJ - ANSWER-Pads of first 2 fingers in front of the tragi of
each ear with mouth open and closed
What position should you lie patient for enema - ANSWER-Left sims' position
, When patient states they are in pain, how and when do you asses pain level
- ANSWER-Ask the patient to rate their pain level on a scale of 1 to 10
after inspecting the abdomen what should be done next - ANSWER-
auscultate
What is a normal Romberg test - ANSWER-Patient standing with feet
together, arms resting at the sides, eyes opening/closing
Cranial Nerve 2: Optic - ANSWER-sensory, vision
Cranial Nerve 3: Oculomotor - ANSWER-M; up, down, medial eye muscle
movements and papillary constriction
Cranial Nerve 4: Trochlear - ANSWER-M; down and medial eye muscle
movement
Cranial Nerve 6: Abducens - ANSWER-M: lateral eye movement
Cranial Nerve 7: Facial - ANSWER-Both: sensory- anterior 2/3 taste of tongue
motor- facial muscle movement
Cranial Nerve 8: Vestibulocochlear - ANSWER-S:hearing and balance
Cranial Nerve 11: Accessory - ANSWER-M; shoulder movement and head
rotation
Cranial Nerve 12: Hypoglossal - ANSWER-M: movement of tongue
