NUR 3066 Health assessment FINAL EXAM | UPDATED
Questions with 100% Verified Answers
Q1: What are the components of a Mental Status Examination?
(Mnemonic)
A: ABCT: Appearance, Behavior, Cognition, Thought process & content
Q2: What does "A" stand for in the ABCT mental status mnemonic?
A: Appearance — dress, hygiene, posture
Q3: What does "B" stand for in the ABCT mental status mnemonic?
A: Behavior — facial expression, speech (rate, clarity, volume), mood/affect
Q4: What does "C" stand for in the ABCT mental status mnemonic?
A: Cognition — orientation (person, place, time, situation), memory, attention, judgment,
insight
Q5: What does "T" stand for in the ABCT mental status mnemonic?
A: Thought process & content — logical? coherent? hallucinations? delusions?
Q6: What demographic components are collected in a health
history? (Ch. 26 ATI)
A: Name, address, contact info, birth date, age, gender (birth certificate + identity),
race/ethnicity, relationship status, occupation, employment, insurance, emergency
contact, family/others in home, advance directives
Q7: MMSE: what is it and what's the cutoff?
A: Mini-Mental State Exam; quick 30-point cognitive screening; <24 = possible cognitive
impairment
Q8: Difference between MMSE and Full Mental Exam?
A: MMSE = abbreviated screening for healthy patient (alertness, orientation, basic CN, gait,
DTRs). Full = comprehensive — all 12 cranial nerves, detailed motor/sensory, stereognosis,
2-point discrimination — for patients with neuro concerns
Q9: What does AVPU stand for?
A: Alert, responds to Verbal stimuli, responds to Pain, Unresponsive (rapid LOC tool)
Q10: Define: Alert
A: Awake, responsive, oriented; looks at and responds to stimuli fully
,Q11: Define: Lethargic
A: Drowsy but easily aroused; opens eyes, responds, then falls back asleep
Q12: Define: Obtunded
A: Opens eyes and responds slowly; appears confused; needs constant stimulation
Q13: Define: Stuporous
A: Deep sleep; arouses only to painful stimuli; verbal response slow or absent; lapses back
when stimuli stops
Q14: Define: Comatose
A: Unarousable; eyes remain closed even with painful stimuli
Q15: Glasgow Coma Scale total range?
A: 3-15 (15 = fully alert; ≤8 = comatose, intubate)
Q16: GCS Eye opening scoring?
A: 4 spontaneous · 3 to voice · 2 to pain · 1 none
Q17: GCS Verbal response scoring?
A: 5 oriented · 4 confused · 3 inappropriate words · 2 incomprehensible sounds · 1 none
Q18: GCS Motor response scoring?
A: 6 obeys commands · 5 localizes pain · 4 flexion withdrawal · 3 abnormal flexion
(decorticate) · 2 abnormal extension (decerebrate) · 1 none
Q19: GCS rule for intubation?
A: "Less than 8, intubate" (≤8 = severe/comatose state)
Q20: Frontal lobe function?
A: Personality, behavior, emotions, intellect, voluntary movement (precentral gyrus); Broca's
area = motor speech
Q21: What happens with frontal lobe damage?
A: Motor weakness, paralysis, personality change, impulsivity; Broca's damage = expressive
aphasia
Q22: What is expressive aphasia (Broca's)?
A: Patient knows what they want to say but can't get it out — garbled speech, frustrated;
comprehension intact
,Q23: Parietal lobe function?
A: Primary sensation (postcentral gyrus), spatial awareness
Q24: What happens with parietal lobe damage?
A: Loss of sensation; impaired stereognosis (ID objects by touch) and graphesthesia (read
numbers traced on skin)
Q25: Temporal lobe function?
A: Hearing, taste, smell; Wernicke's area = language comprehension
Q26: What is receptive aphasia (Wernicke's)?
A: Hears sounds but they have no meaning — like listening to a foreign language; from
temporal lobe damage
Q27: Occipital lobe function?
A: Primary visual receptor center
Q28: Cerebellum function?
A: Balance and coordination
Q29: What happens with cerebellum damage?
A: Ataxia, falls, coordination problems
Q30: Brainstem function?
A: Vital functions — HR, BP, respirations
Q31: What does general cortical damage (stroke) often cause?
A: Mental changes — confusion, disorientation, memory impairment, emotional lability
(rapid/exaggerated mood changes)
Q32: Rinne test: how is it done?
A: Tuning fork on mastoid → then near ear; tests CN VIII
Q33: Weber test: how is it done?
A: Tuning fork on top of head; tests CN VIII
Q34: Normal Rinne result?
A: AC > BC (air conduction greater than bone conduction)
Q35: Normal Weber result?
, A: Sound equal in both ears (midline)
Q36: Rinne result with sensorineural loss?
A: AC > BC (still normal-appearing pattern)
Q37: Rinne result with conductive loss?
A: BC > AC (REVERSED — bone greater than air)
Q38: Weber result with sensorineural loss?
A: Lateralizes to NORMAL/good ear
Q39: Weber result with conductive loss?
A: Lateralizes to AFFECTED/bad ear
Q40: Cranial nerve XI name and function?
A: Spinal Accessory — MOTOR; shrug shoulders, turn head against resistance
Q41: Cranial nerve XII name and function?
A: Hypoglossal — MOTOR; tongue movement (stick out tongue, midline, no deviation)
Q42: What does PERRLA stand for?
A: Pupils Equal Round Reactive to Light and Accommodation
Q43: Which CNs does PERRLA test?
A: CN II (Optic) and CN III (Oculomotor)
Q44: What is accommodation?
A: Pupils constrict when focusing on a near object
Q45: What does a dilated or non-reactive pupil indicate?
A: Ominous sign — possible lesion or increased intracranial pressure; requires prompt
intervention
Q46: What are the most sensitive indicators of neurological status?
A: Pupillary response + Level of Consciousness (LOC)
Q47: Cardiac auscultation mnemonic?
A: All Patients Take Meds — Aortic, Pulmonic, (Erb's), Tricuspid, Mitral
Q48: Aortic valve auscultation location?
Questions with 100% Verified Answers
Q1: What are the components of a Mental Status Examination?
(Mnemonic)
A: ABCT: Appearance, Behavior, Cognition, Thought process & content
Q2: What does "A" stand for in the ABCT mental status mnemonic?
A: Appearance — dress, hygiene, posture
Q3: What does "B" stand for in the ABCT mental status mnemonic?
A: Behavior — facial expression, speech (rate, clarity, volume), mood/affect
Q4: What does "C" stand for in the ABCT mental status mnemonic?
A: Cognition — orientation (person, place, time, situation), memory, attention, judgment,
insight
Q5: What does "T" stand for in the ABCT mental status mnemonic?
A: Thought process & content — logical? coherent? hallucinations? delusions?
Q6: What demographic components are collected in a health
history? (Ch. 26 ATI)
A: Name, address, contact info, birth date, age, gender (birth certificate + identity),
race/ethnicity, relationship status, occupation, employment, insurance, emergency
contact, family/others in home, advance directives
Q7: MMSE: what is it and what's the cutoff?
A: Mini-Mental State Exam; quick 30-point cognitive screening; <24 = possible cognitive
impairment
Q8: Difference between MMSE and Full Mental Exam?
A: MMSE = abbreviated screening for healthy patient (alertness, orientation, basic CN, gait,
DTRs). Full = comprehensive — all 12 cranial nerves, detailed motor/sensory, stereognosis,
2-point discrimination — for patients with neuro concerns
Q9: What does AVPU stand for?
A: Alert, responds to Verbal stimuli, responds to Pain, Unresponsive (rapid LOC tool)
Q10: Define: Alert
A: Awake, responsive, oriented; looks at and responds to stimuli fully
,Q11: Define: Lethargic
A: Drowsy but easily aroused; opens eyes, responds, then falls back asleep
Q12: Define: Obtunded
A: Opens eyes and responds slowly; appears confused; needs constant stimulation
Q13: Define: Stuporous
A: Deep sleep; arouses only to painful stimuli; verbal response slow or absent; lapses back
when stimuli stops
Q14: Define: Comatose
A: Unarousable; eyes remain closed even with painful stimuli
Q15: Glasgow Coma Scale total range?
A: 3-15 (15 = fully alert; ≤8 = comatose, intubate)
Q16: GCS Eye opening scoring?
A: 4 spontaneous · 3 to voice · 2 to pain · 1 none
Q17: GCS Verbal response scoring?
A: 5 oriented · 4 confused · 3 inappropriate words · 2 incomprehensible sounds · 1 none
Q18: GCS Motor response scoring?
A: 6 obeys commands · 5 localizes pain · 4 flexion withdrawal · 3 abnormal flexion
(decorticate) · 2 abnormal extension (decerebrate) · 1 none
Q19: GCS rule for intubation?
A: "Less than 8, intubate" (≤8 = severe/comatose state)
Q20: Frontal lobe function?
A: Personality, behavior, emotions, intellect, voluntary movement (precentral gyrus); Broca's
area = motor speech
Q21: What happens with frontal lobe damage?
A: Motor weakness, paralysis, personality change, impulsivity; Broca's damage = expressive
aphasia
Q22: What is expressive aphasia (Broca's)?
A: Patient knows what they want to say but can't get it out — garbled speech, frustrated;
comprehension intact
,Q23: Parietal lobe function?
A: Primary sensation (postcentral gyrus), spatial awareness
Q24: What happens with parietal lobe damage?
A: Loss of sensation; impaired stereognosis (ID objects by touch) and graphesthesia (read
numbers traced on skin)
Q25: Temporal lobe function?
A: Hearing, taste, smell; Wernicke's area = language comprehension
Q26: What is receptive aphasia (Wernicke's)?
A: Hears sounds but they have no meaning — like listening to a foreign language; from
temporal lobe damage
Q27: Occipital lobe function?
A: Primary visual receptor center
Q28: Cerebellum function?
A: Balance and coordination
Q29: What happens with cerebellum damage?
A: Ataxia, falls, coordination problems
Q30: Brainstem function?
A: Vital functions — HR, BP, respirations
Q31: What does general cortical damage (stroke) often cause?
A: Mental changes — confusion, disorientation, memory impairment, emotional lability
(rapid/exaggerated mood changes)
Q32: Rinne test: how is it done?
A: Tuning fork on mastoid → then near ear; tests CN VIII
Q33: Weber test: how is it done?
A: Tuning fork on top of head; tests CN VIII
Q34: Normal Rinne result?
A: AC > BC (air conduction greater than bone conduction)
Q35: Normal Weber result?
, A: Sound equal in both ears (midline)
Q36: Rinne result with sensorineural loss?
A: AC > BC (still normal-appearing pattern)
Q37: Rinne result with conductive loss?
A: BC > AC (REVERSED — bone greater than air)
Q38: Weber result with sensorineural loss?
A: Lateralizes to NORMAL/good ear
Q39: Weber result with conductive loss?
A: Lateralizes to AFFECTED/bad ear
Q40: Cranial nerve XI name and function?
A: Spinal Accessory — MOTOR; shrug shoulders, turn head against resistance
Q41: Cranial nerve XII name and function?
A: Hypoglossal — MOTOR; tongue movement (stick out tongue, midline, no deviation)
Q42: What does PERRLA stand for?
A: Pupils Equal Round Reactive to Light and Accommodation
Q43: Which CNs does PERRLA test?
A: CN II (Optic) and CN III (Oculomotor)
Q44: What is accommodation?
A: Pupils constrict when focusing on a near object
Q45: What does a dilated or non-reactive pupil indicate?
A: Ominous sign — possible lesion or increased intracranial pressure; requires prompt
intervention
Q46: What are the most sensitive indicators of neurological status?
A: Pupillary response + Level of Consciousness (LOC)
Q47: Cardiac auscultation mnemonic?
A: All Patients Take Meds — Aortic, Pulmonic, (Erb's), Tricuspid, Mitral
Q48: Aortic valve auscultation location?
