NUR 3066 (16) | UPDATED Questions with 100% Verified
Answers
Q1: Components of the Mental Status Examination
A: A: Appearance
B: Behavior
C: Cognition
T: Thought Processes
Q2: Marijuana
A: reddened eyes, tachycardia, dry mouth, increased appetite, loss of
coordination/balance
Q3: Cocaine
A: pupillary dilation, tachycardia or bradycardia, elevated or lowered BP, sweating, chills,
nausea, vomiting, weight loss
Q4: Heroin
A: pinpoint pupils, decrease blood pressure, pulse, respirations and temperature
Q5: Hallucinogens
A: tachycardia, nausea, increased blood pressure, respirations or temperature, loss of
appetite, dry mouth, paranoia, psychosis
Q6: Inhalants
A: slurred speech, lack of coordination, dizziness, delusions
Q7: Methamphetamines
A: pupillary dilation, tachycardia or bradycardia, elevated or decreased blood
pressure, sweating or chills, nausea and vomiting, weight loss
Q8: Temperature
A: Normal -Oral 96.4-99.1 F -Rectal 97.1-100.1 F
Abnormal: Fever (hyperthermia): 100.4+F, Cold (hypothermia) <96.4 F
Rectal temps are most accurate
Tympanic temp utilized in peds often due to ease
Q9: Pulse Rate
A: Normal- 60-100 BPM
Abnormal: Bradycardia <60, Tachycardia >100
Low pulse can be normal
, Pediatrics run higher and have a different scale of normal
Doppler can be used if not palpable
Q10: Pulse Force
A: 2+
0=absent, 1+=weak, thread, 3+=bounding
Reflects strength of heart's stroke volume
Q11: Respirations
A: Normal- 10-20/minutes
Abnormal: Bradypnea <10, Tachypnea>20
Distract patient to get accurate result
Pediatric population differs
Con signal declining status
Count for 30 seconds and x2 (count for full minute if suspected abnormality)
Q12: Oxygen Saturation
A: Normal: >95% on room air
Abnormal: <95% on room air
Lung disease may cause lower normal reading
Move pulse oximeter around if getting odd reading - could be due to placement
Q13: Blood Pressure
A: Systolic= maximum pressure during left ventricular contraction, TOP reading
Diastolic= recoil/resting pressure between each contraction, BOTTOM reading
Pulse Pressure= difference between systolic and diastolic pressures and reflects stroke
volume
Causes of Abnormalities: medical diagnoses, medications, current state
Q14: Performing Blood Pressure Reading
A: Ensure cuff is correct size
Place around arm as directed (practice in lab)
Inflate to maximum level
Deflate cuff slowly and evently
Listen for Korotkoff sounds (Systolic= 1st sound heard, Diastolic= last sound before
silence)
Readings should always be even numbered
Do NOT do BP on mastectomy arm
Q15: Sources of Pain
A: Visceral: from internal organs
Somatic: from musculoskeletal tissues
Deep Somatic: from blood vessels, joints, tendons, muscles, bone
Answers
Q1: Components of the Mental Status Examination
A: A: Appearance
B: Behavior
C: Cognition
T: Thought Processes
Q2: Marijuana
A: reddened eyes, tachycardia, dry mouth, increased appetite, loss of
coordination/balance
Q3: Cocaine
A: pupillary dilation, tachycardia or bradycardia, elevated or lowered BP, sweating, chills,
nausea, vomiting, weight loss
Q4: Heroin
A: pinpoint pupils, decrease blood pressure, pulse, respirations and temperature
Q5: Hallucinogens
A: tachycardia, nausea, increased blood pressure, respirations or temperature, loss of
appetite, dry mouth, paranoia, psychosis
Q6: Inhalants
A: slurred speech, lack of coordination, dizziness, delusions
Q7: Methamphetamines
A: pupillary dilation, tachycardia or bradycardia, elevated or decreased blood
pressure, sweating or chills, nausea and vomiting, weight loss
Q8: Temperature
A: Normal -Oral 96.4-99.1 F -Rectal 97.1-100.1 F
Abnormal: Fever (hyperthermia): 100.4+F, Cold (hypothermia) <96.4 F
Rectal temps are most accurate
Tympanic temp utilized in peds often due to ease
Q9: Pulse Rate
A: Normal- 60-100 BPM
Abnormal: Bradycardia <60, Tachycardia >100
Low pulse can be normal
, Pediatrics run higher and have a different scale of normal
Doppler can be used if not palpable
Q10: Pulse Force
A: 2+
0=absent, 1+=weak, thread, 3+=bounding
Reflects strength of heart's stroke volume
Q11: Respirations
A: Normal- 10-20/minutes
Abnormal: Bradypnea <10, Tachypnea>20
Distract patient to get accurate result
Pediatric population differs
Con signal declining status
Count for 30 seconds and x2 (count for full minute if suspected abnormality)
Q12: Oxygen Saturation
A: Normal: >95% on room air
Abnormal: <95% on room air
Lung disease may cause lower normal reading
Move pulse oximeter around if getting odd reading - could be due to placement
Q13: Blood Pressure
A: Systolic= maximum pressure during left ventricular contraction, TOP reading
Diastolic= recoil/resting pressure between each contraction, BOTTOM reading
Pulse Pressure= difference between systolic and diastolic pressures and reflects stroke
volume
Causes of Abnormalities: medical diagnoses, medications, current state
Q14: Performing Blood Pressure Reading
A: Ensure cuff is correct size
Place around arm as directed (practice in lab)
Inflate to maximum level
Deflate cuff slowly and evently
Listen for Korotkoff sounds (Systolic= 1st sound heard, Diastolic= last sound before
silence)
Readings should always be even numbered
Do NOT do BP on mastectomy arm
Q15: Sources of Pain
A: Visceral: from internal organs
Somatic: from musculoskeletal tissues
Deep Somatic: from blood vessels, joints, tendons, muscles, bone
