NUR 3066 HEALTH ASSESSMENT FINAL EXAM | COMPREHENSIVE
STUDY GUIDE & PRACTICE QUESTIONS 2026/2027
What are the components of a Mental Status Examination? (Mnemonic) - ANS ✔✔ABCT: Appearance,
Behavior, Cognition, Thought process & content
What does "A" stand for in the ABCT mental status mnemonic? - ANS ✔✔Appearance — dress, hygiene,
posture
What does "B" stand for in the ABCT mental status mnemonic? - ANS ✔✔Behavior — facial expression,
speech (rate, clarity, volume), mood/affect
What does "C" stand for in the ABCT mental status mnemonic? - ANS ✔✔Cognition — orientation
(person, place, time, situation), memory, attention, judgment, insight
What does "T" stand for in the ABCT mental status mnemonic? - ANS ✔✔Thought process & content —
logical? coherent? hallucinations? delusions?
What demographic components are collected in a health history? (Ch. 26 ATI) - ANS ✔✔Name, address,
contact info, birth date, age, gender (birth certificate + identity), race/ethnicity, relationship status,
occupation, employment, insurance, emergency contact, family/others in home, advance directives
MMSE: what is it and what's the cutoff? - ANS ✔✔Mini-Mental State Exam; quick 30-point cognitive
screening; <24 = possible cognitive impairment
Difference between MMSE and Full Mental Exam? - ANS ✔✔MMSE = abbreviated screening for healthy
patient (alertness, orientation, basic CN, gait, DTRs). Full = comprehensive — all 12 cranial nerves,
detailed motor/sensory, stereognosis, 2-point discrimination — for patients with neuro concerns
What does AVPU stand for? - ANS ✔✔Alert, responds to Verbal stimuli, responds to Pain, Unresponsive
(rapid LOC tool)
Define: Alert - ANS ✔✔Awake, responsive, oriented; looks at and responds to stimuli fully
Define: Lethargic - ANS ✔✔Drowsy but easily aroused; opens eyes, responds, then falls back asleep
Define: Obtunded - ANS ✔✔Opens eyes and responds slowly; appears confused; needs constant
stimulation
Define: Stuporous - ANS ✔✔Deep sleep; arouses only to painful stimuli; verbal response slow or absent;
lapses back when stimuli stops
Define: Comatose - ANS ✔✔Unarousable; eyes remain closed even with painful stimuli
Glasgow Coma Scale total range? - ANS ✔✔3-15 (15 = fully alert; ≤8 = comatose, intubate)
,GCS Eye opening scoring? - ANS ✔✔4 spontaneous · 3 to voice · 2 to pain · 1 none
GCS Verbal response scoring? - ANS ✔✔5 oriented · 4 confused · 3 inappropriate words · 2
incomprehensible sounds · 1 none
GCS Motor response scoring? - ANS ✔✔6 obeys commands · 5 localizes pain · 4 flexion withdrawal · 3
abnormal flexion (decorticate) · 2 abnormal extension (decerebrate) · 1 none
GCS rule for intubation? - ANS ✔✔"Less than 8, intubate" (≤8 = severe/comatose state)
Frontal lobe function? - ANS ✔✔Personality, behavior, emotions, intellect, voluntary movement
(precentral gyrus); Broca's area = motor speech
What happens with frontal lobe damage? - ANS ✔✔Motor weakness, paralysis, personality change,
impulsivity; Broca's damage = expressive aphasia
What is expressive aphasia (Broca's)? - ANS ✔✔Patient knows what they want to say but can't get it out
— garbled speech, frustrated; comprehension intact
Parietal lobe function? - ANS ✔✔Primary sensation (postcentral gyrus), spatial awareness
What happens with parietal lobe damage? - ANS ✔✔Loss of sensation; impaired stereognosis (ID objects
by touch) and graphesthesia (read numbers traced on skin)
Temporal lobe function? - ANS ✔✔Hearing, taste, smell; Wernicke's area = language comprehension
What is receptive aphasia (Wernicke's)? - ANS ✔✔Hears sounds but they have no meaning — like
listening to a foreign language; from temporal lobe damage
Occipital lobe function? - ANS ✔✔Primary visual receptor center
Cerebellum function? - ANS ✔✔Balance and coordination
What happens with cerebellum damage? - ANS ✔✔Ataxia, falls, coordination problems
Brainstem function? - ANS ✔✔Vital functions — HR, BP, respirations
What does general cortical damage (stroke) often cause? - ANS ✔✔Mental changes — confusion,
disorientation, memory impairment, emotional lability (rapid/exaggerated mood changes)
Rinne test: how is it done? - ANS ✔✔Tuning fork on mastoid → then near ear; tests CN VIII
Weber test: how is it done? - ANS ✔✔Tuning fork on top of head; tests CN VIII
Normal Rinne result? - ANS ✔✔AC > BC (air conduction greater than bone conduction)
Normal Weber result? - ANS ✔✔Sound equal in both ears (midline)
, Rinne result with sensorineural loss? - ANS ✔✔AC > BC (still normal-appearing pattern)
Rinne result with conductive loss? - ANS ✔✔BC > AC (REVERSED — bone greater than air)
Weber result with sensorineural loss? - ANS ✔✔Lateralizes to NORMAL/good ear
Weber result with conductive loss? - ANS ✔✔Lateralizes to AFFECTED/bad ear
Cranial nerve XI name and function? - ANS ✔✔Spinal Accessory — MOTOR; shrug shoulders, turn head
against resistance
Cranial nerve XII name and function? - ANS ✔✔Hypoglossal — MOTOR; tongue movement (stick out
tongue, midline, no deviation)
What does PERRLA stand for? - ANS ✔✔Pupils Equal Round Reactive to Light and Accommodation
Which CNs does PERRLA test? - ANS ✔✔CN II (Optic) and CN III (Oculomotor)
What is accommodation? - ANS ✔✔Pupils constrict when focusing on a near object
What does a dilated or non-reactive pupil indicate? - ANS ✔✔Ominous sign — possible lesion or
increased intracranial pressure; requires prompt intervention
What are the most sensitive indicators of neurological status? - ANS ✔✔Pupillary response + Level of
Consciousness (LOC)
Cardiac auscultation mnemonic? - ANS ✔✔All Patients Take Meds — Aortic, Pulmonic, (Erb's), Tricuspid,
Mitral
Aortic valve auscultation location? - ANS ✔✔2nd ICS, RIGHT sternal border
Pulmonic valve auscultation location? - ANS ✔✔2nd ICS, LEFT sternal border
Erb's point location? - ANS ✔✔3rd ICS, LEFT sternal border (S1 & S2 heard equally)
Tricuspid valve auscultation location? - ANS ✔✔4th ICS, LEFT sternal border (lower)
Mitral valve auscultation location? - ANS ✔✔5th ICS, LEFT midclavicular line (also where PMI is found)
Where is PMI normally located in adults? - ANS ✔✔5th ICS, at or just medial to left midclavicular line
(~7-9 cm from midsternal line)
PMI normal size? - ANS ✔✔One interspace, ~1 × 2 cm; short gentle tap during first half of systole
Where is PMI located in INFANTS? - ANS ✔✔4th ICS, just lateral to midclavicular line (heart is more
horizontal in infants)
STUDY GUIDE & PRACTICE QUESTIONS 2026/2027
What are the components of a Mental Status Examination? (Mnemonic) - ANS ✔✔ABCT: Appearance,
Behavior, Cognition, Thought process & content
What does "A" stand for in the ABCT mental status mnemonic? - ANS ✔✔Appearance — dress, hygiene,
posture
What does "B" stand for in the ABCT mental status mnemonic? - ANS ✔✔Behavior — facial expression,
speech (rate, clarity, volume), mood/affect
What does "C" stand for in the ABCT mental status mnemonic? - ANS ✔✔Cognition — orientation
(person, place, time, situation), memory, attention, judgment, insight
What does "T" stand for in the ABCT mental status mnemonic? - ANS ✔✔Thought process & content —
logical? coherent? hallucinations? delusions?
What demographic components are collected in a health history? (Ch. 26 ATI) - ANS ✔✔Name, address,
contact info, birth date, age, gender (birth certificate + identity), race/ethnicity, relationship status,
occupation, employment, insurance, emergency contact, family/others in home, advance directives
MMSE: what is it and what's the cutoff? - ANS ✔✔Mini-Mental State Exam; quick 30-point cognitive
screening; <24 = possible cognitive impairment
Difference between MMSE and Full Mental Exam? - ANS ✔✔MMSE = abbreviated screening for healthy
patient (alertness, orientation, basic CN, gait, DTRs). Full = comprehensive — all 12 cranial nerves,
detailed motor/sensory, stereognosis, 2-point discrimination — for patients with neuro concerns
What does AVPU stand for? - ANS ✔✔Alert, responds to Verbal stimuli, responds to Pain, Unresponsive
(rapid LOC tool)
Define: Alert - ANS ✔✔Awake, responsive, oriented; looks at and responds to stimuli fully
Define: Lethargic - ANS ✔✔Drowsy but easily aroused; opens eyes, responds, then falls back asleep
Define: Obtunded - ANS ✔✔Opens eyes and responds slowly; appears confused; needs constant
stimulation
Define: Stuporous - ANS ✔✔Deep sleep; arouses only to painful stimuli; verbal response slow or absent;
lapses back when stimuli stops
Define: Comatose - ANS ✔✔Unarousable; eyes remain closed even with painful stimuli
Glasgow Coma Scale total range? - ANS ✔✔3-15 (15 = fully alert; ≤8 = comatose, intubate)
,GCS Eye opening scoring? - ANS ✔✔4 spontaneous · 3 to voice · 2 to pain · 1 none
GCS Verbal response scoring? - ANS ✔✔5 oriented · 4 confused · 3 inappropriate words · 2
incomprehensible sounds · 1 none
GCS Motor response scoring? - ANS ✔✔6 obeys commands · 5 localizes pain · 4 flexion withdrawal · 3
abnormal flexion (decorticate) · 2 abnormal extension (decerebrate) · 1 none
GCS rule for intubation? - ANS ✔✔"Less than 8, intubate" (≤8 = severe/comatose state)
Frontal lobe function? - ANS ✔✔Personality, behavior, emotions, intellect, voluntary movement
(precentral gyrus); Broca's area = motor speech
What happens with frontal lobe damage? - ANS ✔✔Motor weakness, paralysis, personality change,
impulsivity; Broca's damage = expressive aphasia
What is expressive aphasia (Broca's)? - ANS ✔✔Patient knows what they want to say but can't get it out
— garbled speech, frustrated; comprehension intact
Parietal lobe function? - ANS ✔✔Primary sensation (postcentral gyrus), spatial awareness
What happens with parietal lobe damage? - ANS ✔✔Loss of sensation; impaired stereognosis (ID objects
by touch) and graphesthesia (read numbers traced on skin)
Temporal lobe function? - ANS ✔✔Hearing, taste, smell; Wernicke's area = language comprehension
What is receptive aphasia (Wernicke's)? - ANS ✔✔Hears sounds but they have no meaning — like
listening to a foreign language; from temporal lobe damage
Occipital lobe function? - ANS ✔✔Primary visual receptor center
Cerebellum function? - ANS ✔✔Balance and coordination
What happens with cerebellum damage? - ANS ✔✔Ataxia, falls, coordination problems
Brainstem function? - ANS ✔✔Vital functions — HR, BP, respirations
What does general cortical damage (stroke) often cause? - ANS ✔✔Mental changes — confusion,
disorientation, memory impairment, emotional lability (rapid/exaggerated mood changes)
Rinne test: how is it done? - ANS ✔✔Tuning fork on mastoid → then near ear; tests CN VIII
Weber test: how is it done? - ANS ✔✔Tuning fork on top of head; tests CN VIII
Normal Rinne result? - ANS ✔✔AC > BC (air conduction greater than bone conduction)
Normal Weber result? - ANS ✔✔Sound equal in both ears (midline)
, Rinne result with sensorineural loss? - ANS ✔✔AC > BC (still normal-appearing pattern)
Rinne result with conductive loss? - ANS ✔✔BC > AC (REVERSED — bone greater than air)
Weber result with sensorineural loss? - ANS ✔✔Lateralizes to NORMAL/good ear
Weber result with conductive loss? - ANS ✔✔Lateralizes to AFFECTED/bad ear
Cranial nerve XI name and function? - ANS ✔✔Spinal Accessory — MOTOR; shrug shoulders, turn head
against resistance
Cranial nerve XII name and function? - ANS ✔✔Hypoglossal — MOTOR; tongue movement (stick out
tongue, midline, no deviation)
What does PERRLA stand for? - ANS ✔✔Pupils Equal Round Reactive to Light and Accommodation
Which CNs does PERRLA test? - ANS ✔✔CN II (Optic) and CN III (Oculomotor)
What is accommodation? - ANS ✔✔Pupils constrict when focusing on a near object
What does a dilated or non-reactive pupil indicate? - ANS ✔✔Ominous sign — possible lesion or
increased intracranial pressure; requires prompt intervention
What are the most sensitive indicators of neurological status? - ANS ✔✔Pupillary response + Level of
Consciousness (LOC)
Cardiac auscultation mnemonic? - ANS ✔✔All Patients Take Meds — Aortic, Pulmonic, (Erb's), Tricuspid,
Mitral
Aortic valve auscultation location? - ANS ✔✔2nd ICS, RIGHT sternal border
Pulmonic valve auscultation location? - ANS ✔✔2nd ICS, LEFT sternal border
Erb's point location? - ANS ✔✔3rd ICS, LEFT sternal border (S1 & S2 heard equally)
Tricuspid valve auscultation location? - ANS ✔✔4th ICS, LEFT sternal border (lower)
Mitral valve auscultation location? - ANS ✔✔5th ICS, LEFT midclavicular line (also where PMI is found)
Where is PMI normally located in adults? - ANS ✔✔5th ICS, at or just medial to left midclavicular line
(~7-9 cm from midsternal line)
PMI normal size? - ANS ✔✔One interspace, ~1 × 2 cm; short gentle tap during first half of systole
Where is PMI located in INFANTS? - ANS ✔✔4th ICS, just lateral to midclavicular line (heart is more
horizontal in infants)
