NURS 425 UPDATED ACTUAL Exam
Questions and CORRECT Answers
different parts of the General Survey - CORRECT ANSWER - The general survey is a
study of the whole person, covering the general health state and any obvious physical
characteristics
→physical appearance , body structure (stature, nutrition, symmetric), mobility (gait, ROM), and
behavior.
What does Systolic/Diastolic mean? - CORRECT ANSWER - - The systolic pressure is
the maximum pressure felt on the artery during left - ventricular contraction, or systole. (higher
#)
- The diastolic pressure is the elastic recoil, or resting, pressure that the blood exerts constantly
between each contraction. (LOWER #)
What are healthy or "normal" vital signs for an adult? - CORRECT ANSWER - - temp:
98.6 (range 96.4-99.1)
* rectal measures .7-1 degree higher
*axillary measures 1 degree lower
- BP: <120/<80 in adults
-pulse: 50-95 bpm
-resp: 20 (range 16-25)
How do you take a blood pressure? - CORRECT ANSWER - MANUAL: • Allow at least
a 5-minute rest before measuring
• Sit the patient in a chair with their back supported ) feet on the floor and legs should not be
crossed
• Arm must be supported at heart level and find Bracial artery
• inflate cuff until artery pulsates and 20-30 beyond (this helps to avoid ausculatory gap), deflate
cuff quickly and wait 15- 30 seconds
• place bell @ brachial and use DIAPHRAGM
, • Inflate cuff and then deflate slowly waiting to hear FIRST APPerance, MUFFLE OF
SOUNDS, AND DISAPPERANCE
How to take different temperatures - CORRECT ANSWER - oral: place at base of tongue
either at front or sublingual pocket, pt keeps lips close and hold in place 3-4 minutes (BE
AWARE OF HOT OR ICED LIQUIDS WAIT 15 MIN)
rectal: red tip, most accurate, use lubriacation to enter 1 in and leave in place 2.5 min
tymphatic: eardrum (same vascular at hypothalamus), place probe in 2-3 seconds (ADULTS:
position ear up and back, KIDS: PULL DOWN)
How do you describe a pulse? - CORRECT ANSWER - 3+ FULL/ BOUNDING (ex
exercise, anxiety, svt)
2+ NORMAL
1+ WEAK/ THREADY (low blood flow/ circulation)
0 ABSENT
Different spine shapes - CORRECT ANSWER - Spine: should be stright with normal
convex thoracic curve and concave lumbar
Kyphosis: enhances thoracic curve typically in older adults (hunched forward)
lordosis: pronounced lumbar curve usually in obese (stomach pushed forward)
scoliosis: S SHAPE:
- Lateral curvature of thoracic and lumbar segments of the spine, usually with some rotation of
involved vertebral bodies
Anatomy of the spine - CORRECT ANSWER - -33 vertebrae in total (7 cervical
vertebrae,12 thoracic, 5 lumbar, 5 sacral vertebrae, 3/4 coccygeal vertebrae
- SPINOUS process c7-t1, inferior angle of scapular between T7 and T8, imaginary line
connecting highest points cross at L4
- spine has 4 curves and looking from the side is an s shape (cervical/lumbar= concave and in)
(thoracic/ sacrococcygeal = convex and out)
- intervertebral disc w/ nucleous pulposus cushion the spine like a shock absorber.
Questions and CORRECT Answers
different parts of the General Survey - CORRECT ANSWER - The general survey is a
study of the whole person, covering the general health state and any obvious physical
characteristics
→physical appearance , body structure (stature, nutrition, symmetric), mobility (gait, ROM), and
behavior.
What does Systolic/Diastolic mean? - CORRECT ANSWER - - The systolic pressure is
the maximum pressure felt on the artery during left - ventricular contraction, or systole. (higher
#)
- The diastolic pressure is the elastic recoil, or resting, pressure that the blood exerts constantly
between each contraction. (LOWER #)
What are healthy or "normal" vital signs for an adult? - CORRECT ANSWER - - temp:
98.6 (range 96.4-99.1)
* rectal measures .7-1 degree higher
*axillary measures 1 degree lower
- BP: <120/<80 in adults
-pulse: 50-95 bpm
-resp: 20 (range 16-25)
How do you take a blood pressure? - CORRECT ANSWER - MANUAL: • Allow at least
a 5-minute rest before measuring
• Sit the patient in a chair with their back supported ) feet on the floor and legs should not be
crossed
• Arm must be supported at heart level and find Bracial artery
• inflate cuff until artery pulsates and 20-30 beyond (this helps to avoid ausculatory gap), deflate
cuff quickly and wait 15- 30 seconds
• place bell @ brachial and use DIAPHRAGM
, • Inflate cuff and then deflate slowly waiting to hear FIRST APPerance, MUFFLE OF
SOUNDS, AND DISAPPERANCE
How to take different temperatures - CORRECT ANSWER - oral: place at base of tongue
either at front or sublingual pocket, pt keeps lips close and hold in place 3-4 minutes (BE
AWARE OF HOT OR ICED LIQUIDS WAIT 15 MIN)
rectal: red tip, most accurate, use lubriacation to enter 1 in and leave in place 2.5 min
tymphatic: eardrum (same vascular at hypothalamus), place probe in 2-3 seconds (ADULTS:
position ear up and back, KIDS: PULL DOWN)
How do you describe a pulse? - CORRECT ANSWER - 3+ FULL/ BOUNDING (ex
exercise, anxiety, svt)
2+ NORMAL
1+ WEAK/ THREADY (low blood flow/ circulation)
0 ABSENT
Different spine shapes - CORRECT ANSWER - Spine: should be stright with normal
convex thoracic curve and concave lumbar
Kyphosis: enhances thoracic curve typically in older adults (hunched forward)
lordosis: pronounced lumbar curve usually in obese (stomach pushed forward)
scoliosis: S SHAPE:
- Lateral curvature of thoracic and lumbar segments of the spine, usually with some rotation of
involved vertebral bodies
Anatomy of the spine - CORRECT ANSWER - -33 vertebrae in total (7 cervical
vertebrae,12 thoracic, 5 lumbar, 5 sacral vertebrae, 3/4 coccygeal vertebrae
- SPINOUS process c7-t1, inferior angle of scapular between T7 and T8, imaginary line
connecting highest points cross at L4
- spine has 4 curves and looking from the side is an s shape (cervical/lumbar= concave and in)
(thoracic/ sacrococcygeal = convex and out)
- intervertebral disc w/ nucleous pulposus cushion the spine like a shock absorber.
