Abnormal Behavior Correct Answers flat, depressed, angry,
sad, anxious, hostile, distrustful, dysarthria/dysphasia, clothing
too small/large, heavy clothing constantly, body odor/stench of
alcohol
abnormal body structure Correct Answers excessively short or
tall, centripetal obesity, anorexic, tripod, resists lying down,
fetal position, elongated arm span, missing extremities
abnormal mobility Correct Answers shuffle, dragging foot,
limping, propulsion, limited joint range, paralysis,
ticks/tremors/seizures
abnormal physical appearance Correct Answers appears old
than age stated (chronic illness or alcoholism),
confused/drowsy/lethargic,
pallor/cyanosis/jaundice/erythema/lesions,
immobile/asymmetric/drooping, cardiac/respiratory signs/pain
with grimace
Alcohol use disorder Correct Answers intoxication: unsteady
gait, flushed face, incoordination
withdrawal: nausea/vomiting, malaise, autonomic hyperactivity,
headache, anxiety, irritability/depression (extreme: withdrawal
delirium)
ANA Code of Ethics Correct Answers The nurse promotes,
advocates for, and strives to protect the health, safety, and rights
of the patient.
,Annular or circular lesion Correct Answers begins in center and
spreads to periphery
Areas of General Survey and measurement Correct Answers
physical appearance, body structure, mobility, behavior
Weight, height, BMI, waist circumference
assessing cognitive functioning Correct Answers Orientation
(person, place, and time)
Attention span ("stimulus bound" - confusion, negativism)
Recent Memory (ask 24 hour diet recall)
Remote Memory (ask verifiable past events)
New Learning (4 random words and have them recall 5 minutes
later)
Assessing common aging adult skin Correct Answers Elasticity
(decreases), sweat and sebaceous glands (decrease), senile
purpura (discoloration), skin breakdown (slow cell replacement),
hair matrix (functioning melanocytes decrease - gray fine hair)
Auscultation Correct Answers listening to sounds produced by
the body, such as the heart, blood vessels, lungs, and abdomen -
with the use of a stethoscope. This is to look FOR extra sounds
that may be a cause for concern.
behavior Correct Answers Facial expression, mood and affect,
speech, speech pattern, dress, personal hygiene
, benzodiazepine use disorder Correct Answers Intoxication:
similar to alcohol, impaired gait, talkativeness, slurred speech,
impaired memory, sexual aggressiveness,
Withdrawal: anxiety, nausea/vomiting, malaise, autonomic
hyperactivity, grand Mal seizures
Biographical data Correct Answers name, address, phone
number, age, birthdate/place, sex, marital status, race/ethnicity,
occupation, preferred language
Blood Pressure Correct Answers - mmHg (millimeters of
mercury)
- normal range: around 120/80 mmHg
Body Mass Index (BMI) Correct Answers practical marker of
healthy weight for height and an indicator of obesity and
malnutrition, but does not consider muscle mass.
underweight: <18.5 kg/m2
Overweight: 25 -29
Obesity (1-3): > 30
Body structure Correct Answers normal range for: stature,
nutrition, symmetry, posture, position, body build/contour,
obvious physical deformities
Bulla Correct Answers larger than 1 cm, usually single
chamber, superficial in dermis and ruptures easily
cocaine/amphetamine use disorder Correct Answers
intoxication: pupillary dilation, tachycardia or bradycardia,