Nurs. 258 Final Exam with correct answers
Order of physical assessment skills - CORRECT ANSWERS
✔✔inspection, palpation, (percussion), auscultation
Frequency of VS - CORRECT ANSWERS ✔✔MD orders, critical
situations, after surgery, during blood transfusions, changes in pt
status
Factors that affect temperature - CORRECT ANSWERS ✔✔age,
exercise, hormone changes, circadian rhythm, stress, environment,
illness and injury
Apical pulse location - CORRECT ANSWERS ✔✔5th intercostal
space, left mid-clavicular line
Why might you take an apical pulse? - CORRECT ANSWERS
✔✔most accurate and when pt is on cardiac meds
Factors the influence pulse - CORRECT ANSWERS ✔✔exercise,
temperature, emotions, meds, hemorrhage, postural changes
,Factors affecting respirations - CORRECT ANSWERS ✔✔exercise,
acute pain, anxiety, smoking, body position, medications,
neurological injury, hemoglobin function
Alterations in breathing pattern - CORRECT ANSWERS
✔✔bradypnea, tachypnea, hyperpnea, apnea, hyperventilation,
hypoventilation
Factors affecting BP - CORRECT ANSWERS ✔✔age, stress,
ethnicity (AA men higher BP), meds, activity, weight, smoking
How much change in BP would indicate orthostatic hypotension? -
CORRECT ANSWERS ✔✔drop in 20 mmHg systolic
How would you estimate systolic BP? - CORRECT ANSWERS
✔✔1. palpate radial pulse
2. inflate cuff until pulse disappears
3. deflate cuff slowly
4. record mmHg where pulse reappears
,When should the nurse start checking BP on children? - CORRECT
ANSWERS ✔✔not until at least 3 years old
When assessing children specifically for mental status what area's
should the nurse check? - CORRECT ANSWERS ✔✔head control,
motor development, sensory development (7-9 months fully
developed), Babinski reflex (children fan toes, adults flex feet and
toes)
LOC: alert - CORRECT ANSWERS ✔✔Awake or readily aroused,
oriented, fully aware of external and internal stimuli and responds
appropriately
LOC: lethargic - CORRECT ANSWERS ✔✔not fully alert, drifts off
to sleep easily, can be aroused to name but is drowsy, responses
seem slow and fuzzy, spontaneous movements are decreased
LOC: obtunded - CORRECT ANSWERS ✔✔transitional state
between lethargy and stupor, difficult to arouse-needs loud shout or
vigorous shakes, acts confused when is aroused, speech may be
mumbled and incoherent
, LOC: stupor or semi-coma - CORRECT ANSWERS ✔✔responds
only to vigorous shaking or pain with groans, may have appropriate
motor response
LOC: coma - CORRECT ANSWERS ✔✔completely unconscious,
no response to pain or any external
light coma = some reflex
deep coma = no motor response
LOC: delirium (Acute Confusional State) - CORRECT ANSWERS
✔✔clouding of consciousness, impaired alertness, inattentive,
agitation, hallucinations, disoriented
mood vs affect - CORRECT ANSWERS ✔✔mood is external
expression of state of mind vs affect being more internal prolonged
display of feelings
Abstract reasoning - CORRECT ANSWERS ✔✔pondering a deeper
meaning beyond the concrete and literal
Order of physical assessment skills - CORRECT ANSWERS
✔✔inspection, palpation, (percussion), auscultation
Frequency of VS - CORRECT ANSWERS ✔✔MD orders, critical
situations, after surgery, during blood transfusions, changes in pt
status
Factors that affect temperature - CORRECT ANSWERS ✔✔age,
exercise, hormone changes, circadian rhythm, stress, environment,
illness and injury
Apical pulse location - CORRECT ANSWERS ✔✔5th intercostal
space, left mid-clavicular line
Why might you take an apical pulse? - CORRECT ANSWERS
✔✔most accurate and when pt is on cardiac meds
Factors the influence pulse - CORRECT ANSWERS ✔✔exercise,
temperature, emotions, meds, hemorrhage, postural changes
,Factors affecting respirations - CORRECT ANSWERS ✔✔exercise,
acute pain, anxiety, smoking, body position, medications,
neurological injury, hemoglobin function
Alterations in breathing pattern - CORRECT ANSWERS
✔✔bradypnea, tachypnea, hyperpnea, apnea, hyperventilation,
hypoventilation
Factors affecting BP - CORRECT ANSWERS ✔✔age, stress,
ethnicity (AA men higher BP), meds, activity, weight, smoking
How much change in BP would indicate orthostatic hypotension? -
CORRECT ANSWERS ✔✔drop in 20 mmHg systolic
How would you estimate systolic BP? - CORRECT ANSWERS
✔✔1. palpate radial pulse
2. inflate cuff until pulse disappears
3. deflate cuff slowly
4. record mmHg where pulse reappears
,When should the nurse start checking BP on children? - CORRECT
ANSWERS ✔✔not until at least 3 years old
When assessing children specifically for mental status what area's
should the nurse check? - CORRECT ANSWERS ✔✔head control,
motor development, sensory development (7-9 months fully
developed), Babinski reflex (children fan toes, adults flex feet and
toes)
LOC: alert - CORRECT ANSWERS ✔✔Awake or readily aroused,
oriented, fully aware of external and internal stimuli and responds
appropriately
LOC: lethargic - CORRECT ANSWERS ✔✔not fully alert, drifts off
to sleep easily, can be aroused to name but is drowsy, responses
seem slow and fuzzy, spontaneous movements are decreased
LOC: obtunded - CORRECT ANSWERS ✔✔transitional state
between lethargy and stupor, difficult to arouse-needs loud shout or
vigorous shakes, acts confused when is aroused, speech may be
mumbled and incoherent
, LOC: stupor or semi-coma - CORRECT ANSWERS ✔✔responds
only to vigorous shaking or pain with groans, may have appropriate
motor response
LOC: coma - CORRECT ANSWERS ✔✔completely unconscious,
no response to pain or any external
light coma = some reflex
deep coma = no motor response
LOC: delirium (Acute Confusional State) - CORRECT ANSWERS
✔✔clouding of consciousness, impaired alertness, inattentive,
agitation, hallucinations, disoriented
mood vs affect - CORRECT ANSWERS ✔✔mood is external
expression of state of mind vs affect being more internal prolonged
display of feelings
Abstract reasoning - CORRECT ANSWERS ✔✔pondering a deeper
meaning beyond the concrete and literal
