NR 302 Exam 1
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1. A, B, C, & T -Appearance: Person's posture is erect, with no involuntary movements. Dress
and grooming are appropriate for season and setting.
-Posture
-Body Movements
-Dress
-Grooming & Hygiene
-pupils
- Behavior: Person is alert, with appropriate facial expression and fluent,
understandable speech. Affect and verbal responses are appropriate.
-Level of consciousness
-Facial Expressions
-Speech (quality,pacing,articulation ,word choice)
-Cognition: Oriented to time, person, place. Able to attend cooperatively with
examiner. Recent and remote memory intact. Can recall four unrelated words at
5-, 10-, and 30-minute testing intervals. Future plans include returning home
and to local university once individual therapy is established and medication
is adjusted.
-Orientation
-Attention Span
-Recent and remote memory
-New learning- the four unrelated words test
-judgement
-Thought processes:Perceptions and thought processes are logical and coher-
ent. No suicidal ideation.
-Thought process
-Thought content
, NR 302 Exam 1
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-Perceptions
-Screen for suicidal thoughts
2. ADLs -(Activities of Daily Living): Basic self-care tasks people do every day (bathing,
dressing, eating, toileting, moving).
3. Affect -is a temporary expression of feelings or state of mind, and mood is more
durable, a prolonged display of feelings that color the whole emotional life.
4. AUDIT -(Alcohol Use Disorders Identification Test):A screening tool developed by the
World Health Organization (WHO) to identify people with risky or harmful
alcohol use.
It's a 10-question questionnaire that looks at:
Alcohol consumption
Drinking behavior
Alcohol-related problems
5. AUDIT-C -(Alcohol Use Disorders Identification Test-Consumption): A shorter, 3-ques-
tion version of the AUDIT that focuses only on alcohol consumption (how often,
how much, and binge drinking).
6. Behavior -Person is alert, with appropriate facial expression and fluent, understandable
speech. Affect and verbal responses are appropriate.
-The way a person acts, responds, or conducts themselves, especially in re-
sponse to their environment, emotions, or needs.
7. Binge drinking -Drinking a large amount of alcohol in a short period of time, leading to
intoxication.
8. Biographic data -Basic identifying information about a patient collected during a health as-
sessment.
Includes things like:
=I
, NR 302 Exam 1
Study online at https://quizlet.com/_hsuyc8
Name
Age/date of birth
Gender
Address/contact info
Marital status
Occupation
Primary language
Source of history (self, family, caregiver)
9. Body structure -How the patient's body is built and organized, including posture, symmetry,
height, weight, and overall physical appearance.
10. CAGE test -A quick, 4-question screening tool used to identify potential alcohol prob-
lems.
Questions focus on:
=I
Cut down: Have you felt you should cut down on drinking?
Annoyed: Have people annoyed you by criticizing your drinking?
Guilty: Have you felt guilty about drinking?
Eye-opener: Have you ever had a drink first thing in the morning?
Scoring:
2 or more "yes" answers = likely alcohol misuse and need for further assess-
ment.
11. CIWA-Ar -(Clinical Institute Withdrawal Assessment for Alcohol, revised):A tool nurses
use to measure the severity of alcohol withdrawal symptoms and guide treat-
ment.
It scores symptoms such as:
=I
Nausea/vomiting
Tremors
Sweating
, NR 302 Exam 1
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Anxiety
Agitation
Hallucinations
Orientation (awareness)
Scoring:
0-9 = Minimal withdrawal
10-19 = Moderate withdrawal
20+ = Severe withdrawal (risk of complications like seizures, delirium tremens)
12. Consciousness -A person's awareness of themselves and their environment, including the
ability to respond to stimuli.
Alert: Fully awake and responsive
Lethargic: Drowsy but arousable
Obtunded: Hard to wake, slow responses
Stuporous: Only responds to strong/painful stimuli
Comatose: No response
13. Delirium -is an acute confusional change or loss of consciousness and perceptual
disturbance; it may accompany acute illness (e.g., pneumonia, alcohol/drug
intoxication), and it is usually resolved when the underlying cause is treated.
14. Dementia -is a gradual, progressive process, causing decreased cognitive function even
though the person is fully conscious and awake; it is not reversible
15. Family history -Information about the health of a patient's close relatives (parents, siblings,
grandparents) that helps identify risks for diseases or conditions that may run
in families.
16. FICA questions -A tool nurses use to assess a patient's spiritual needs during a health assess-
ment.
Study online at https://quizlet.com/_hsuyc8
1. A, B, C, & T -Appearance: Person's posture is erect, with no involuntary movements. Dress
and grooming are appropriate for season and setting.
-Posture
-Body Movements
-Dress
-Grooming & Hygiene
-pupils
- Behavior: Person is alert, with appropriate facial expression and fluent,
understandable speech. Affect and verbal responses are appropriate.
-Level of consciousness
-Facial Expressions
-Speech (quality,pacing,articulation ,word choice)
-Cognition: Oriented to time, person, place. Able to attend cooperatively with
examiner. Recent and remote memory intact. Can recall four unrelated words at
5-, 10-, and 30-minute testing intervals. Future plans include returning home
and to local university once individual therapy is established and medication
is adjusted.
-Orientation
-Attention Span
-Recent and remote memory
-New learning- the four unrelated words test
-judgement
-Thought processes:Perceptions and thought processes are logical and coher-
ent. No suicidal ideation.
-Thought process
-Thought content
, NR 302 Exam 1
Study online at https://quizlet.com/_hsuyc8
-Perceptions
-Screen for suicidal thoughts
2. ADLs -(Activities of Daily Living): Basic self-care tasks people do every day (bathing,
dressing, eating, toileting, moving).
3. Affect -is a temporary expression of feelings or state of mind, and mood is more
durable, a prolonged display of feelings that color the whole emotional life.
4. AUDIT -(Alcohol Use Disorders Identification Test):A screening tool developed by the
World Health Organization (WHO) to identify people with risky or harmful
alcohol use.
It's a 10-question questionnaire that looks at:
Alcohol consumption
Drinking behavior
Alcohol-related problems
5. AUDIT-C -(Alcohol Use Disorders Identification Test-Consumption): A shorter, 3-ques-
tion version of the AUDIT that focuses only on alcohol consumption (how often,
how much, and binge drinking).
6. Behavior -Person is alert, with appropriate facial expression and fluent, understandable
speech. Affect and verbal responses are appropriate.
-The way a person acts, responds, or conducts themselves, especially in re-
sponse to their environment, emotions, or needs.
7. Binge drinking -Drinking a large amount of alcohol in a short period of time, leading to
intoxication.
8. Biographic data -Basic identifying information about a patient collected during a health as-
sessment.
Includes things like:
=I
, NR 302 Exam 1
Study online at https://quizlet.com/_hsuyc8
Name
Age/date of birth
Gender
Address/contact info
Marital status
Occupation
Primary language
Source of history (self, family, caregiver)
9. Body structure -How the patient's body is built and organized, including posture, symmetry,
height, weight, and overall physical appearance.
10. CAGE test -A quick, 4-question screening tool used to identify potential alcohol prob-
lems.
Questions focus on:
=I
Cut down: Have you felt you should cut down on drinking?
Annoyed: Have people annoyed you by criticizing your drinking?
Guilty: Have you felt guilty about drinking?
Eye-opener: Have you ever had a drink first thing in the morning?
Scoring:
2 or more "yes" answers = likely alcohol misuse and need for further assess-
ment.
11. CIWA-Ar -(Clinical Institute Withdrawal Assessment for Alcohol, revised):A tool nurses
use to measure the severity of alcohol withdrawal symptoms and guide treat-
ment.
It scores symptoms such as:
=I
Nausea/vomiting
Tremors
Sweating
, NR 302 Exam 1
Study online at https://quizlet.com/_hsuyc8
Anxiety
Agitation
Hallucinations
Orientation (awareness)
Scoring:
0-9 = Minimal withdrawal
10-19 = Moderate withdrawal
20+ = Severe withdrawal (risk of complications like seizures, delirium tremens)
12. Consciousness -A person's awareness of themselves and their environment, including the
ability to respond to stimuli.
Alert: Fully awake and responsive
Lethargic: Drowsy but arousable
Obtunded: Hard to wake, slow responses
Stuporous: Only responds to strong/painful stimuli
Comatose: No response
13. Delirium -is an acute confusional change or loss of consciousness and perceptual
disturbance; it may accompany acute illness (e.g., pneumonia, alcohol/drug
intoxication), and it is usually resolved when the underlying cause is treated.
14. Dementia -is a gradual, progressive process, causing decreased cognitive function even
though the person is fully conscious and awake; it is not reversible
15. Family history -Information about the health of a patient's close relatives (parents, siblings,
grandparents) that helps identify risks for diseases or conditions that may run
in families.
16. FICA questions -A tool nurses use to assess a patient's spiritual needs during a health assess-
ment.
