NUR 3065 Exam 3 Questions With Complete Solutions
Identify the components of level of consciousness (LOC)
assessment
o 1 = Alert
• Awake, oriented, appropriate responses
o 2 = Lethargic (somnolent)
• Not fully alert, drowsy, drifts off to sleep when not stimulated,
arouses to sound in a normal voice, responds appropriately but
slowly, inattentive
o 3 = Obtunded
• Transitional state between lethargy and stupor, may not be a
category, difficult to arouse
♣ Needs a loud shout or a vigorous shake, acts confused when
aroused, sleeps most of the time, speech may be mumbled and
incoherent - not appropriate communication
o 4 = Stupor or Semi-Coma
• Unconscious, responsive to persistent and vigorous shakes or
pain, mumbles, groans, motor response appropriate to pain,
reflexes intact
o 5 = Coma
• Unconscious, not responsive to pain or stimuli
abdominal Auscultation Correct Answers ♣ Bowel sounds
active in all 4 quadrants
♣ No aortic or renal bruit heard
♣ *Percussion or palpation can alter bowel sound frequency
♣ *Borborygmus = stomach growling
abdominal inspection
♣ Correct Answers Contour flat/slightly rounded
,♣ No pulsations/slight aortic pulsation seen
abdominal Palpation Correct Answers ♣ Superficially: no
tenderness, masses, or hernias
•No horizontal or vertical inguinal lymphadenopathy
♣ Deep: no tenderness, masses, or hernias
•Kidneys/spleen nonpalpable
•Negative Murphy's sign
♣ Guarding: Voluntary
•Tightening of the abdominal muscles occurs when a person is
cold, tense, or ticklish
•Bilateral
•May decrease with exhalation
♣ Guarding: Involuntary
•Rigidity is constant, a board-like hardness
•May be unilateral
•Protective mechanism with acute inflammation of the
peritoneum
abdominal Percussion Correct Answers ♣ Tympanic in all 4
quadrants
♣ Dullness over liver
♣ Liver span 6-12 cm
♣ No CVA tenderness
Abdominal reflex testing pattern Correct Answers • Use a blunt
object such as a key or tongue blade
• Stroke the abdomen lightly on each side in an inward and
downward direction
• Note contraction of abdominal muscles and deviation of the
umbilicus towards the stimulus
,Achilles tendon reflex Correct Answers • Client in sitting
position
• Dorsiflex the foot at the ankle
• Strike the Achilles tendon
• Watch and feel for plantar flexion at the ankle
Active ROM Correct Answers voluntary, demonstrate and have
pt. repeat
Acute Gout: Correct Answers a type of arthritis
• Caused by excess uric acid in the blood
• Produces urate crystals
• Risk factors
♣ Alcohol consumption
♣ Obesity
♣ Dehydration
♣ Rich foods - chocolate, seafood, meat or red wine high in
purines
♣ Some medications - especially diuretics
• S&S: episodic
♣ Redness
♣ Swelling
♣ Heat
♣ Extreme pain attacks can last few days or many weeks
Ankylosis Correct Answers stiffness or fixation of a joint
ascites Correct Answers ♣ Abdomen is fluid-filled (not gas-
filled)
, ♣ Gas-filled intestines will float to the top of the fluid-filled
abdomen; thus, there should be periumbilical tympany with
dullness in the flank
♣ One should mark the level of dullness on the skin and then
turn the patient on one side for a full minute; a change in the
level of dullness is termed shifting dullness and usually indicates
more than 500 ml of ascitic fluid
♣ Dull percussion over fluid
assessing mental status: adolescents Correct Answers • Follow
same A-B-C-T guidelines for adults
♣ **ABCT = association for behavioral and cognitive therapies
assessing mental status: infants and children Correct Answers •
Denver II screening test - gives a chance to interact directly with
child to assess mental status
♣ For child from birth to 6 years of age, Denver II helps identify
those who may be slow to develop in behavioral, language,
cognitive, and psychosocial areas
♣ An additional language test is the Denver Articulation
Screening Examination
• Behavioral Checklist - for school age children, ages 7-11, is
tool given to parent along with the history
♣ Covers five major areas: mood, play, school, friends, and
family relations
♣ It is easy to administer and lasts about 5 minutes
assessing mental status: older adults Correct Answers • Check
sensory status, vision, and hearing before any aspect of the
mental status
Identify the components of level of consciousness (LOC)
assessment
o 1 = Alert
• Awake, oriented, appropriate responses
o 2 = Lethargic (somnolent)
• Not fully alert, drowsy, drifts off to sleep when not stimulated,
arouses to sound in a normal voice, responds appropriately but
slowly, inattentive
o 3 = Obtunded
• Transitional state between lethargy and stupor, may not be a
category, difficult to arouse
♣ Needs a loud shout or a vigorous shake, acts confused when
aroused, sleeps most of the time, speech may be mumbled and
incoherent - not appropriate communication
o 4 = Stupor or Semi-Coma
• Unconscious, responsive to persistent and vigorous shakes or
pain, mumbles, groans, motor response appropriate to pain,
reflexes intact
o 5 = Coma
• Unconscious, not responsive to pain or stimuli
abdominal Auscultation Correct Answers ♣ Bowel sounds
active in all 4 quadrants
♣ No aortic or renal bruit heard
♣ *Percussion or palpation can alter bowel sound frequency
♣ *Borborygmus = stomach growling
abdominal inspection
♣ Correct Answers Contour flat/slightly rounded
,♣ No pulsations/slight aortic pulsation seen
abdominal Palpation Correct Answers ♣ Superficially: no
tenderness, masses, or hernias
•No horizontal or vertical inguinal lymphadenopathy
♣ Deep: no tenderness, masses, or hernias
•Kidneys/spleen nonpalpable
•Negative Murphy's sign
♣ Guarding: Voluntary
•Tightening of the abdominal muscles occurs when a person is
cold, tense, or ticklish
•Bilateral
•May decrease with exhalation
♣ Guarding: Involuntary
•Rigidity is constant, a board-like hardness
•May be unilateral
•Protective mechanism with acute inflammation of the
peritoneum
abdominal Percussion Correct Answers ♣ Tympanic in all 4
quadrants
♣ Dullness over liver
♣ Liver span 6-12 cm
♣ No CVA tenderness
Abdominal reflex testing pattern Correct Answers • Use a blunt
object such as a key or tongue blade
• Stroke the abdomen lightly on each side in an inward and
downward direction
• Note contraction of abdominal muscles and deviation of the
umbilicus towards the stimulus
,Achilles tendon reflex Correct Answers • Client in sitting
position
• Dorsiflex the foot at the ankle
• Strike the Achilles tendon
• Watch and feel for plantar flexion at the ankle
Active ROM Correct Answers voluntary, demonstrate and have
pt. repeat
Acute Gout: Correct Answers a type of arthritis
• Caused by excess uric acid in the blood
• Produces urate crystals
• Risk factors
♣ Alcohol consumption
♣ Obesity
♣ Dehydration
♣ Rich foods - chocolate, seafood, meat or red wine high in
purines
♣ Some medications - especially diuretics
• S&S: episodic
♣ Redness
♣ Swelling
♣ Heat
♣ Extreme pain attacks can last few days or many weeks
Ankylosis Correct Answers stiffness or fixation of a joint
ascites Correct Answers ♣ Abdomen is fluid-filled (not gas-
filled)
, ♣ Gas-filled intestines will float to the top of the fluid-filled
abdomen; thus, there should be periumbilical tympany with
dullness in the flank
♣ One should mark the level of dullness on the skin and then
turn the patient on one side for a full minute; a change in the
level of dullness is termed shifting dullness and usually indicates
more than 500 ml of ascitic fluid
♣ Dull percussion over fluid
assessing mental status: adolescents Correct Answers • Follow
same A-B-C-T guidelines for adults
♣ **ABCT = association for behavioral and cognitive therapies
assessing mental status: infants and children Correct Answers •
Denver II screening test - gives a chance to interact directly with
child to assess mental status
♣ For child from birth to 6 years of age, Denver II helps identify
those who may be slow to develop in behavioral, language,
cognitive, and psychosocial areas
♣ An additional language test is the Denver Articulation
Screening Examination
• Behavioral Checklist - for school age children, ages 7-11, is
tool given to parent along with the history
♣ Covers five major areas: mood, play, school, friends, and
family relations
♣ It is easy to administer and lasts about 5 minutes
assessing mental status: older adults Correct Answers • Check
sensory status, vision, and hearing before any aspect of the
mental status
