216 NUR Pre-test | Questions and Answers | 2025 Update | 100% Correct

216 NUR Pre-test | Questions and Answers | 2025 Update | 100% Correct 1. High Ammonia can cause what - ANSWERhepatic encephalopathy, confusion, lethargy, asterixis, coma 2. When assessing a nutritional history for a client, ask them how much they've eaten/drank in the past - ANSWERday or 3 days (dietary recall) 3. Critical thinking versus nursing process - ANSWERcognitive action/skill versus plan of care/collection of information 4. Four assessment techniques - ANSWERInspection Palpation Percussion Auscultation 5. 3 levels of health promotion/prevention - ANSWERprimary prevention (immunizations, nutrition); secondary prevention (screenings); tertiary prevention (disease education) 6. QSEN competencies - ANSWER1. Patient-centered care 2. Teamwork and collaboration 3. Evidence-based practice 4. Quality improvement 5. Safety 6. Informatics 7. NEVER ASK A WHY QUESTION!!!! - ANSWERputs the patient on defensive mode, not therapeutic aphasia - ANSWERtrouble understanding/speaking language 8. A good way to always communicate/educate a patient is by - ANSWERasking for their preference(s) ROS - ANSWERreview of systems/symptoms Pertinent Negatives - ANSWERNegative findings that warrant no care or intervention. Pertinent Positives - ANSWERspecific symptoms that raise the physician's suspicion for a particular disease Primary v secondary data sources - ANSWERpatient v anything else (family, med docs) Malaise - ANSWERa vague feeling of physical discomfort or uneasiness 9. Three phases of the interview - ANSWERIntroduction Working Summary Introductory phase of Interview - ANSWERIntroduce yourself and explain your role. Establish rapport and trust. Explain the purpose or reason for the interview. Tell your patient that you will be taking some notes. State the approximate time frame for the interview. Ask the patient if she or he is comfortable. 10. Working phase of the Interview - ANSWERCollect information about the patient. Ask open- and closed-ended questions. Have the patient self-report his or her history. Be alert to nonverbal communication cues. Identify patient problems and goals. Ask the patient if he or she has any questions. 11. Summary phase of the Interview - ANSWERClarify the patient's report, needs, feelings, and concerns. Summarize the patient's self-report by restating the findings and self-report to validate that both you and the patient perceive the health history the same way. Confirm that the goals were validated by both you and the patient. 6 Functions of Clinical Judgement - ANSWER1. Recognize clues (what matters most?) 2. Analyze cues (what does it mean?) 3. Prioritize Hypothesis (where do I start?) 4. Generate solutions (what can I do?) 5. Take action (what will I do?) 6. Evaluate outcomes (did it help) 12. Auscultation - ANSWERlistening to sounds within the body with a stethoscope Communicating to members of health care team - ANSWER1. Identity of client 2. Provide info of current situation 3. Provide info of background situation 4. Vital signs 5. Provide suggestions 6. Repeat orders back that are given via the provider Palpation assessment (what are they looking for?) - ANSWERSkin temperature, moisture, and abnormalities 13. Therapeutic communication beginning steps - ANSWER1. Introduce yourself 2. Determine what the client wants you to call them 3. Make sure client is comfortable 14. Therapeutic communication health history steps (after beginning steps) - ANSWER1. Perform general survey/measure vital signs 2. Reduce environmental noise/limit distractions 3. Note clients nonverbal communication 15. Things to avoid when giving Therapeutic communication - ANSWER1. Use of medical jargon 2. Giving advice 3. Ignoring feelings 4. Offering false reassurance 5. Asking "Why?" questions 16. Examination Sequence (non-abdomen) - ANSWER1. Inspection 2. Palpation 3. Percussion 4. Auscultation 17. Examination Sequence (Abdomen examination) - ANSWER1. Inspection 2. Auscultation 3. Palpation and Percussion 18. When checking for skin temperature during a physical examination, you use what part of the hand? - ANSWERdorsal surface 19. Name the four clarifying techniques of Therapeutic communication - ANSWER1. Restating 2. Reflecting 3. Paraphrasing 4. Exploring 20. How many generations should you collect medical history for? - ANSWERThree generations When conducting a review of systems, in what order do you examine? - ANSWERHead to toe 21. FICA assessment - ANSWERFaith and belief Importance/Influence Community Address in care SDOH - ANSWERsocial determinants of health 22. ROLES of communication to patient - ANSWERRelaxed body language Open posture Leaning in Eye contact Sit squarely towards patient 23. Nurse-Client relationship phases - ANSWER*Orientation (establish trust/rapport) *Working (develop and implement solutions to concerns and evaluate interventions) *Termination (closure of the relationship) c/o - ANSWERcomplaining of 24. LMNOPQRSTUVW - ANSWERLocation Mechanism New Problem Onset Palliative/Provocative Quality Radiation Severity/Setting Timing Unusual symptoms Valid Work 25. OLDCARTS - ANSWEROnset Location Duration Characteristics Aggravating and Alleviating Factors Related Symptoms Treatment Severity of Symptoms 26. HITS Screening Tool - ANSWERAssess patient safety (Domestic Violence and Intimate Partner Violence (IPV)) CAGE-AID Screening Tool - ANSWERAssess alcohol and drug use 27. SENC SAFETY ALERT - ANSWERnever leave a patient alone if you suspect that they are having suicidal thoughts Oral temperature range - ANSWER97.6-99.6 tympanic temperature range - ANSWER98.2-100 F 28. Temporal temperature range - ANSWER98.7-100.5 F Rectal temperature range - ANSWER98.6-100.6 Hyperpyrexia - ANSWERfever above 105.8 antipyretic - ANSWERMedication used to reduce a fever preparation for blood pressure assessment - ANSWER§Ask patient if he or she has smoked or had caffeine in the last 30 minutes (If yes, wait until 30 minutes have lapsed.) §If patient is ambulatory, have patient sit in a chair with feet flat on the floor for 5 minutes. §Ask patient not to move, talk, or cross legs while you assess the blood pressure. Inflate BP cuff to - ANSWER30 to 40 mm hypotension - ANSWER90/60 mmHg Hypertension - ANSWER140/90 mmHg hypovelimic - ANSWERlow volume of blood 29. Orthostatic Blood Pressure - ANSWERa blood pressure taken in 3 different positions w/5 mins between each - lying, sitting and standing Abnormal findings in Orthostatic Blood Pressure - ANSWER§Pulse rate increases by 20 bpm §Systolic BP decreases by 20 mm Hg §Diastolic BP decreases by 10 mm Hg 30. triage - ANSWERthe medical screening of patients to determine their relative priority of need and the proper place of treatment Rhonchi - ANSWERCoarse, low-pitched breath sounds heard in patients with chronic mucus in the upper airways. Contact precautions PPE - ANSWERgown and gloves 31. Droplet precautions PPE - ANSWERgloves, gown, mask Airborne precautions PPE - ANSWERneg pressure room respirator N95 for TB 32. Direct inspection versus indirect inspection - ANSWERobserving with the eyes versus observing with special equipment (auscultation) Inspection requires the use of three senses - ANSWER‒Seeing ‒Hearing ‒Smelling Three parts of the hand are used to assess surface characteristics - ANSWER•Finger pads •Dorsal surface of the hand •Ulnar surface Finger pads - ANSWERfine textural details & pulse checks Dorsal surface of the hand - ANSWERtemperature Ulnar surface - ANSWERvibrations 33. Light palpation vs deep palpation - ANSWERlight palpation: surface characteristics [1/2in] deep palpation: blunt or continuous pressure [2in] (intermittently- do not cause damage) bi-manual palpation: requires the use of both hands What to look for in light palpation - ANSWER•Texture •Masses •Moisture •Pulsations •Temperature •Tenderness 34. What to look for in deep palpation - ANSWER•Organ size and position •Masses Tenderness Purpose of percussion - ANSWER•size •consistency •borders of body organs •presence or absence of fluid in body areas. 35. What to look for in percussion - ANSWER•Pitch •Intensity •Duration •Quality of sound Emphysema - ANSWERa condition in which the air sacs of the lungs are damaged and enlarged, causing breathlessness/difficulty breathing. quality of percussion sounds - ANSWER•Tympany •Dullness •Resonance •Hyperresonance •Flatness 36. Purpose of indirect percussion - ANSWERTo assess the size, consistency, and borders of body organs, and the presence or absence of fluid in body areas to avoid pain Tympany is heard over - ANSWERabdominal areas that may be filled with abdominal gas. Dullness is heard over - ANSWERsolid organs, fluid collection, or areas of consolidation (such as a tumor or mass). Resonance is heard over - ANSWERnormal lung fields 37. Hyperresonance is heard over - ANSWERair-filled spaces such as lung fields in a patient with emphysema Flatness is heard over - ANSWERincreased tissue density such as bones. Purpose of indirect fist percussion - ANSWERto assess organ tenderness Anthropometry - ANSWERMeasurement of the human body 38. Assessment of a client's nutritional status is based on - ANSWER•Physical examination •Anthropometric measurements •Laboratory data •Food intake information Hematocrit - ANSWERpercentage of blood volume occupied by red blood cells Ferritin - ANSWERstorage form of iron Folate - ANSWERVitamin B9 (folic acid) 39. Mean Corpuscular Volume (MCV) - ANSWERIndicates the oxygen-carrying capacity of blood pernicious anemia (PA) - ANSWERanemia resulting when digestive system absorbs insufficient amount of vitamin B12; vitamin B12 is necessary for erythrocyte production Low hemoglobin requires - ANSWERblood transfusion Ageusia - ANSWERloss of taste Dysgeusia - ANSWERdistortion of the sense of taste anorexia - ANSWERdecreased appetite Chief Complaint (CC) - ANSWERthe main reason for the patient's visit 40. History of Present Illness (HPI) - ANSWEROLDCARTS (onset-location-duration-character-allieving/aggravating-time-severity) How to calculate BMI - ANSWERweight (kg) / height (m^2) Abnormal findings assessing BMI and each index range - ANSWER§Underweight: BMI of 18.5 §Overweight BMI 25 - 29.9 §Obese: BMI 30 to 39 §Morbidly Obese: BMI 40 Abnormal findings assessing Abdominal Circumference - ANSWER§Males: 102 cm (40 inches) §Females: 88 cm (35 inches) Anhedonia - ANSWERinability to experience pleasure anergia - ANSWERlack of energy flat affect - ANSWERa lack of emotional responsiveness correct sequence to perform a physical assessment - ANSWERGeneral survey temperature pulse respiratory rate blood pressure Wong-Baker FACES scale - ANSWERa pain assessment tool that asks patients (often children) to select one of several faces indicating expressions that convey a range from no pain through the worst pain PAIN-AD - ANSWERPain Assessment in Advanced Dementia Scale Critical Care Pain Observation Tool (CPOT) - ANSWERfor the non communicative patient -facial expression -body movements -muscle tension (eval by passive flexion extension and of upper extremities) -compliance with ventilator OR vocalization 0-8 scale - 0 being no movement 8 being most movement pyrosis - ANSWERheartburn Core temperature sites - ANSWERrectum, tympanic, temporal Non-Core Temperature sites - ANSWERaxillary, oral what side do you lay on for rectal temperature taking - ANSWERleft side subjective information collected after you further assess the reason for seeking care is called - ANSWERHistory of Present Illness (HPI) Acetaminophen - ANSWERTylenol nephrolithiasis - ANSWERkidney stones Fevers affect pulse rate or blood pressure? - ANSWERPulse rate The reason why the client sought medical care is usually considered what type of data? - ANSWERsubjective Findings that the nurse observes, including through seeing, hearing, and touching, are considered - ANSWERobjective data Fasciculation - ANSWERrapid continuous twitching of resting muscle without movement of limb Functional Assessment findings - ANSWERscreens the safety of independent living, the need for home health services, and quality of life priapism - ANSWERpersistent and painful erection capillary refill - ANSWERA test that evaluates distal circulatory system function by squeezing (blanching) blood from an area such as a nail bed and watching the speed of its return after releasing the pressure. biopsy - ANSWERdiagnostic examination of a piece of tissue from the living body shingles and what it looks like - ANSWERviral disease that affects the peripheral nerves and causes blisters on the skin that follow the course of the affected nerves pallor - ANSWERpaleness Erythema - ANSWERredness of the skin skin turgor - ANSWERMeasure of hydration, which tests how quickly the skin returns to its normal position after being pinched Bulla - ANSWERLarge blister containing watery fluid Macule - ANSWERflat, colored spot on the skin Nodule - ANSWERcircular, elevated, solid lesion Patch - ANSWERa flat, discolored area on the skin Papule - ANSWERsmall, solid, raised lesion on surface of the skin Plaque - ANSWERsuperficial, flat, or slightly raised differentiated patch Pustule - ANSWERelevation of skin containing pus Vesicle - ANSWERcircular collection of free fluid wheal - ANSWERsmall, round, raised area on the skin that may be accompanied by itching; usually seen in allergic reactions Eccymosis - ANSWERbruising petechiae - ANSWERa small red or purple spot caused by bleeding into the skin. Hematoma - ANSWERa solid swelling of clotted blood within the tissues. telangiectasia (spider angioma) - ANSWERa tiny, red blood vessel lesion formed by the dilation of a group of blood vessels radiating from a central arteriole, most commonly on the face, neck, or chest purpura - ANSWERmultiple pinpoint hemorrhages and accumulation of blood under the skin nevi - ANSWERmoles alopecia areata - ANSWERAutoimmune disorder that causes the affected hair follicles to be mistakenly attacked by a person's own immune system; usually begins with one or more small, round, smooth bald patches on the scalp. clubbing - ANSWERabnormal curving of the nails that is often accompanied by enlargement of the fingertips cellulitis - ANSWERInfection of skin cells Herpetic whitlow - ANSWERHerpes of the finger onychomycosis - ANSWERfungal infection of the nail Sterile cotton-tipped applicator - ANSWERTo measure the length, width, depth of the wound Stages of pressure ulcers - ANSWER●Stage I - persistent redness; skin is intact with visible, non blanchable redness over a localized area, typically over bony prominence; changes in skin temperature, tissue consistency and sensation (pain, itching) ●Stage II - involves the dermis with partial thickness loss which presents as shallow open ulcer that can be shiny or dry; can also present as a blister that is intact or open/ruptured; wound bed is red pink color without slough or bruising ●Stage III - full thickness tissue loss with subcutaneous fat possibly visible; bone, tendon or muscle are not exposed or directly palpable ●Stage IV - full thickness tissue loss with bone, tendon, or muscle visible Maceration - ANSWERsoftening of tissue by soaking diaphoresis - ANSWERprofuse sweating decubitis - ANSWERbed sores Psoriasis - ANSWERchronic skin condition producing red lesions covered with silvery scales HPI - ANSWERhistory of present illness (the story of the symptoms) Rhinosinusitis - ANSWERinflammation of the sinuses Migraine - ANSWERSevere unilateral, pulsating pain Xerostomia - ANSWERdry mouth risk for aspiration - ANSWERstate in which a person is at risk for entry of secretions, solids, or fluids into the tracheobronchial passages Angioedema - ANSWERswelling of the blood vessels (allergies, certain syndromes) What may cause spasms? - ANSWERMedication, ticks (turrets), parkinsons expressive aphasia - ANSWERThe inability to produce language ( despite being able to understand language) receptive aphasia - ANSWERThe inability to understand language (despite being able to hear it and produce it) fissure - ANSWERcracking of the skin, an opening; a groove; a split Malocclusion - ANSWERany deviation from the normal positioning of the upper teeth against the lower teeth Leukoplakia - ANSWERthickened, white, leathery-looking spots on the inside of the mouth. can develop into oral cancer Torticollis - ANSWERhead tilt due to shortening or spasm of one sternomastoid muscle bruit (auscultation of the throat) - ANSWERblowing, swooshing sound heard through a stethoscope when an artery is partially occluded Presbycusis - ANSWERage related hearing loss Cranial Nerve VIII - ANSWERTransmits sound •Frequency (pitch) •Intensity (volume) Tinnitus - ANSWERringing in the ears Types of hearing loss - ANSWER•Conductive hearing loss •Sensorineural hearing loss •Mixed hearing loss •Conductive hearing loss - ANSWERsound is not conducted through the outer ear canal due to excessive cerumen buildup Sensorineural hearing loss - ANSWERresults from damage to the inner ear (cochlea) or to the nerve pathways from the inner ear to the brain Mixed hearing loss - ANSWERincludes both conductive & sensorineural hearing loss Otitis Media - ANSWERinflammation of the middle ear conjunctiva - ANSWERDelicate membrane lining the eyelids and covering the eyeball diplopia - ANSWERdouble vision Nyctalopia - ANSWERpoor vision at night or in faint light nystagmus - ANSWERInvoluntary rapid eye movements when would you see a cloudy lens? - ANSWERcataracts or glaucoma Munchausen syndrome - ANSWERa mental health disorder where you falsify, exaggerate, or induce physical, emotional or cognitive disorders prophylactic - ANSWERpertaining to preventing or protecting against disease or pregnancy Ectropion - ANSWERoutward turning of the rim of the eyelid Entropion - ANSWERinward turning of the rim of the eyelid pterygium - ANSWERconjunctival growth Ptosis - ANSWERdrooping of eyelid Snellen chart - ANSWERused to measure visual acuity (patient stands 20 ft away) Legal blindness - ANSWER20/200 myopia - ANSWERnearsightedness hyperopia - ANSWERfarsightedness presbyopia - ANSWERimpaired vision as a result of aging Ishihara plate - ANSWERTest for color vision Amsler grid - ANSWERtest to assess central vision and to assist in the diagnosis of age-related macular degeneration Abnormal findings in Convergence & Accommodation - ANSWERPupils do not converge or constrict PERRLA - ANSWERPupils, equal, round, reactive to light and accommodation trigeminal neuralgia - ANSWERsudden, intense, severe lightning-like pain due to an inflammation of the fifth cranial nerve Rosenbaum chart - ANSWERused to assess near vision acuity confrontation test - ANSWERa gross measure of peripheral vision Orthopnea - ANSWERdifficulty breathing when lying down paroxysmal nocturnal dyspnea - ANSWERsudden awakening from sleeping with shortness of breath pleuritic chest pain - ANSWERA stabbing pain upon taking a deep breath pneumothorax - ANSWERair in the pleural cavity pack year calculation - ANSWER# of packs of cigs a day x number of years Clubbing of fingers - ANSWERCaused by chronic hypoxia. Presence of this is suggestive of pulmonary disease. AP to transverse diameter - ANSWERnormal: 1:2 barrel: 1:1 Crepitus - ANSWERa crackling or grating sound usually of bones fremitus - ANSWERa palpable vibration from the spoken voice felt over the chest wall pleural effusion - ANSWERabnormal accumulation of fluid in the pleural space thoracentesis - ANSWERsurgical puncture to remove fluid from the pleural space intercostal muscle retraction - ANSWERpatient is struggling to breathe (shouldn't be able to see muscles normally) What/Where to auscultate for bronchovesicular sounds - ANSWERmedium-pitched; heard lateral to midsternal line on mid-chest anteriorly & between scapulae posteriorly adventitious breath sounds - ANSWERAbnormal breath sounds such as wheezing, stridor, rhonchi, and crackles. Kussmaul respirations - ANSWERDeep, rapid breathing; usually the result of an accumulation of certain acids when insulin is not available in the body. stridor - ANSWERstrained, high-pitched sound heard on inspiration caused by obstruction in the pharynx or larynx Cheyne-Stokes respiration - ANSWERbreathing characterized by an increase of depth and sometimes rate to a maximum level, followed by a decrease, resulting in apnea eupnea - ANSWERnormal breathing expectorate - ANSWERcough up and spit out mucus from the respiratory tract