2025 LATEST UPDATED |NURSING 206 EXAM 4 CONTENT / 570+
在中文中
COMPLETE QUESTIONS AND CORRECT DETAILED ANSWERS
|GRADED A+
Mental status - (ANSWER)- Is defined as the degree of competence that a person shows in intellectual,
emotional, psychological, and personality function
- Changes may become evident when there is change in the patient's orientation to person, place, or time;
attention span; or memory
- Assess by determining orientation, memory, calculation ability, communication skills, judgement, and
abstraction
Orientation - (ANSWER)- Ask the patient what year it is, where he or she is, and his or her name
- Time is the first orientation to be lost
- Place is the second orientation to be lost
- Person is the last orientation to be lost
Immediate Recall - (ANSWER)- Ask the patient to repeat the names of three unrelated objects that are
spoken slowly such as "dog," "cloud," and "apple."
Recent Memory - (ANSWER)- Give the patient a short time to view four or five objects and tell him or
her that you will ask about these objects in a few minutes.
- After about 10 minutes ask the patient to name the objects
,- All objects should be remembered
在中文中
Remote Memory - (ANSWER)- Ask the patient about his or her mother's maiden name, high school
attended, or a subject of common knowledge
Impaired Memory - (ANSWER)- Occurs with various neurological and psychiatric disorders, such as
anxiety or depression.
- Loss of immediate and recent memory with retention of remote memory suggests dementia
INSPECT skeleton and extremities for alignment and symmetry - (ANSWER)- Observe the patient
standing upright and straight from the front, back, and sides
- The patient should stand erect
- The body appears relatively symmetric when one side is compared with the other
- The spine should be straight with expected curvatures (cervical concave, thoracic convex, lumbar
concave)
- The knees should be in a straight line between the hips and ankles, and the feet should be flat on the
floor and pointing directly forward
Abnormal Findings:
- Irregular posture or any asymmetry or misalignment warrants further assessment
,INSPECT muscles for symmetry and size - (ANSWER)- Muscles should appear symmetric bilaterally. (
在中文中
No person has exact side-to-side symmetry)
- Muscle circumference can be measured with a cloth or paper tape measure to provide a baseline for
future comparisons and make side-to-side comparisons
- The dominant side usually is slightly larger than the nondominant side
- To ensure consistency of measurement, record the number of centimeters above or below the joint where
the muscle was measured or include a diagram
- Measurement differences less than 1 cm usually are not significant
Abnormal Findings:
- Atrophy of muscle mass bilaterally may indicate lack of nerve stimulation such as a spinal cord injury or
malnutrition
- Unilateral muscle atrophy may be from disuse, from pain on movement, or after removal of a cast
- Fasciculations (muscle twitching of a single muscle group) may be caused by adverse effects of drugs
- Fasciculations are localized, whereas spasms (involuntary muscle contractions) tend to be more
generalized
PALPATE bones for pain; joints for pain, temperature, and edema; and muscles for pain, temperature,
edema, and tone - (ANSWER)Procedure:
- Using the pads of the thumb and fingers of both hands, palpate both of the patient's shoulders
simultaneously
, - Compare one side with the other
在中文中
- Move distally and symmetrically, palpating the muscles, bones, and joints of the arms and hands
- Use the dorsum of your hands to detect temperature of muscles and joints
- Use the same technique for palpating the legs from hips to the toes
Findings:
- Bones should be painless on palpation
- No pain or edema should be detected on palpation of joints or muscles
- The joints and muscles should be the same temperature as the surrounding tissue
- Muscles should feel firm, not hard or soft
Abnormal Findings:
- Pain, edema, and warmth in affected joints are found bilaterally in patients with rheumatoid arthritis
- Pain and enlarged joints with pain on movement are found unilaterally in patients with osteoarthritis
- Pain, heat, or edema over bones or muscles may indicate a tumor, inflammation, or trauma
- Muscle atrophy may be evident by a decrease u muscle tone
OBSERVE range of motion for major joints and adjacent muscles for pain on movement, joint stability,
and deformity - (ANSWER)Procedure:
- Ask the patient to perform range of motion actively
在中文中
COMPLETE QUESTIONS AND CORRECT DETAILED ANSWERS
|GRADED A+
Mental status - (ANSWER)- Is defined as the degree of competence that a person shows in intellectual,
emotional, psychological, and personality function
- Changes may become evident when there is change in the patient's orientation to person, place, or time;
attention span; or memory
- Assess by determining orientation, memory, calculation ability, communication skills, judgement, and
abstraction
Orientation - (ANSWER)- Ask the patient what year it is, where he or she is, and his or her name
- Time is the first orientation to be lost
- Place is the second orientation to be lost
- Person is the last orientation to be lost
Immediate Recall - (ANSWER)- Ask the patient to repeat the names of three unrelated objects that are
spoken slowly such as "dog," "cloud," and "apple."
Recent Memory - (ANSWER)- Give the patient a short time to view four or five objects and tell him or
her that you will ask about these objects in a few minutes.
- After about 10 minutes ask the patient to name the objects
,- All objects should be remembered
在中文中
Remote Memory - (ANSWER)- Ask the patient about his or her mother's maiden name, high school
attended, or a subject of common knowledge
Impaired Memory - (ANSWER)- Occurs with various neurological and psychiatric disorders, such as
anxiety or depression.
- Loss of immediate and recent memory with retention of remote memory suggests dementia
INSPECT skeleton and extremities for alignment and symmetry - (ANSWER)- Observe the patient
standing upright and straight from the front, back, and sides
- The patient should stand erect
- The body appears relatively symmetric when one side is compared with the other
- The spine should be straight with expected curvatures (cervical concave, thoracic convex, lumbar
concave)
- The knees should be in a straight line between the hips and ankles, and the feet should be flat on the
floor and pointing directly forward
Abnormal Findings:
- Irregular posture or any asymmetry or misalignment warrants further assessment
,INSPECT muscles for symmetry and size - (ANSWER)- Muscles should appear symmetric bilaterally. (
在中文中
No person has exact side-to-side symmetry)
- Muscle circumference can be measured with a cloth or paper tape measure to provide a baseline for
future comparisons and make side-to-side comparisons
- The dominant side usually is slightly larger than the nondominant side
- To ensure consistency of measurement, record the number of centimeters above or below the joint where
the muscle was measured or include a diagram
- Measurement differences less than 1 cm usually are not significant
Abnormal Findings:
- Atrophy of muscle mass bilaterally may indicate lack of nerve stimulation such as a spinal cord injury or
malnutrition
- Unilateral muscle atrophy may be from disuse, from pain on movement, or after removal of a cast
- Fasciculations (muscle twitching of a single muscle group) may be caused by adverse effects of drugs
- Fasciculations are localized, whereas spasms (involuntary muscle contractions) tend to be more
generalized
PALPATE bones for pain; joints for pain, temperature, and edema; and muscles for pain, temperature,
edema, and tone - (ANSWER)Procedure:
- Using the pads of the thumb and fingers of both hands, palpate both of the patient's shoulders
simultaneously
, - Compare one side with the other
在中文中
- Move distally and symmetrically, palpating the muscles, bones, and joints of the arms and hands
- Use the dorsum of your hands to detect temperature of muscles and joints
- Use the same technique for palpating the legs from hips to the toes
Findings:
- Bones should be painless on palpation
- No pain or edema should be detected on palpation of joints or muscles
- The joints and muscles should be the same temperature as the surrounding tissue
- Muscles should feel firm, not hard or soft
Abnormal Findings:
- Pain, edema, and warmth in affected joints are found bilaterally in patients with rheumatoid arthritis
- Pain and enlarged joints with pain on movement are found unilaterally in patients with osteoarthritis
- Pain, heat, or edema over bones or muscles may indicate a tumor, inflammation, or trauma
- Muscle atrophy may be evident by a decrease u muscle tone
OBSERVE range of motion for major joints and adjacent muscles for pain on movement, joint stability,
and deformity - (ANSWER)Procedure:
- Ask the patient to perform range of motion actively
