NUR 431 EXAM QUESTIONS WITH
COMPLETE SOLUTIONS
normal pulse - Answer-60 to 100 beats per minute
Force of the pulse can be rated as 3+ (full bounding), 2+ (normal), 1+ (weak), 0 (absent)
normal respirations - Answer-Adult rate is 10-20 breaths/minute
normal blood Pressure - Answer-Average BP is 120/80
normal pulse Oxygen - Answer-> 95%
Temperature (Oral, Rectal, Tympanic, Temporal) - Answer--Oral: in the sublingual
pocket
-Rectal: most accurate, most invasive. Use for comatose patients, patients in shock,
patients who have facial dysfunctions. Insert probe 2-3 cm into the rectum.
-Tympanic: place probe in person's ear canal
-Temporal Artery: sliding the probe across the forehead and behind the ear
If using the improper technique: can get the wrong temperature
Pulse - Answer-Palpate radial pulse. Count the number of beats for 30 seconds then
multiply by 2. Start your count at zero for the first beat.
Less than 50 bpm = brachycardia.
More than 95 or 100 bpm = tachycardia
Respirations - Answer-Count for 30 seconds and multiply by 2.
Watch chest rise/fall. Or place a hand on their abdomen/upper chest.
Blood Pressure - Answer-The patient's feet should be flat on the floor. Palpate brachial
artery, located above the antecubital fossa. Center cuff 1 inch above the brachial artery.
Inflate the cuff 20-30 mmHg above maximum inflation level. The bell of the stethoscope
picks up lower-pitched sounds but can also use the diaphragm.
BP Improper Technique - Answer--deflating cuff too quickly- gives falsely low systolic or
falsely high diastolic.
-Deflating cuff too slowly- gives a falsely high diastolic
PQRSTU - Answer-P: Provocation/Palliation
Q: Quality/Quantity
R: Region/Radiation
S: Severity Scale
T: Timing
U: Understanding the patient's perception of the problem
, acute pain - Answer-pain that is felt suddenly from injury, disease, trauma, or surgery
short-term, self-limiting, often predictable trajectory; stops after injury heals
chronic pain - Answer--Patients can live with chronic pain for months or years
-Patients can adapt to chronic pain over time
-Patients try and give little indication that they are in pain, which gives a higher risk for
underdetection
full mental status examination - Answer-behavior changes
brain lesions (trauma, tumor, brain attack)
aphasia (secondary to brain damage, difficulty getting words out)
-symptoms of psychiatric mental illness
When any abnormality in effect or behavior is discovered
When emotional and cognitive functioning is questioning
Collecting 4 types of patient data - Answer-Complete (total health) database- Complete
health history and full physical
Focused or problem-centered database- Concerns one problem/part of the body
Follow-up database- status of the problem. The problem should be evaluated at regular
and appropriate intervals
Is the prob getting worse or better?
Emergency database-Urgent rapid collection of crucial information
Diagnostic reasoning - Answer-the process of analyzing health data and drawing a
conclusion to identify a diagnosis.
environment - Answer-Privacy (private room, closed curtain)
Know when to talk to adolescents vs to their parents
Do assessments with nudity last
Only give the patient a gown right before the physical examination
Sit at equal length with no distraction
Room at a comfortable temperature
Sufficient lighting
Quiet
4-5 feet between client
Blockers for Communication - Answer--not being attentive
-no fiddling
-look professional
-be impartial
-a nod to express interest/ understanding
-limit reaction to patients answers
-sit facing patient at eye level
COMPLETE SOLUTIONS
normal pulse - Answer-60 to 100 beats per minute
Force of the pulse can be rated as 3+ (full bounding), 2+ (normal), 1+ (weak), 0 (absent)
normal respirations - Answer-Adult rate is 10-20 breaths/minute
normal blood Pressure - Answer-Average BP is 120/80
normal pulse Oxygen - Answer-> 95%
Temperature (Oral, Rectal, Tympanic, Temporal) - Answer--Oral: in the sublingual
-Rectal: most accurate, most invasive. Use for comatose patients, patients in shock,
patients who have facial dysfunctions. Insert probe 2-3 cm into the rectum.
-Tympanic: place probe in person's ear canal
-Temporal Artery: sliding the probe across the forehead and behind the ear
If using the improper technique: can get the wrong temperature
Pulse - Answer-Palpate radial pulse. Count the number of beats for 30 seconds then
multiply by 2. Start your count at zero for the first beat.
Less than 50 bpm = brachycardia.
More than 95 or 100 bpm = tachycardia
Respirations - Answer-Count for 30 seconds and multiply by 2.
Watch chest rise/fall. Or place a hand on their abdomen/upper chest.
Blood Pressure - Answer-The patient's feet should be flat on the floor. Palpate brachial
artery, located above the antecubital fossa. Center cuff 1 inch above the brachial artery.
Inflate the cuff 20-30 mmHg above maximum inflation level. The bell of the stethoscope
picks up lower-pitched sounds but can also use the diaphragm.
BP Improper Technique - Answer--deflating cuff too quickly- gives falsely low systolic or
falsely high diastolic.
-Deflating cuff too slowly- gives a falsely high diastolic
PQRSTU - Answer-P: Provocation/Palliation
Q: Quality/Quantity
R: Region/Radiation
S: Severity Scale
T: Timing
U: Understanding the patient's perception of the problem
, acute pain - Answer-pain that is felt suddenly from injury, disease, trauma, or surgery
short-term, self-limiting, often predictable trajectory; stops after injury heals
chronic pain - Answer--Patients can live with chronic pain for months or years
-Patients can adapt to chronic pain over time
-Patients try and give little indication that they are in pain, which gives a higher risk for
underdetection
full mental status examination - Answer-behavior changes
brain lesions (trauma, tumor, brain attack)
aphasia (secondary to brain damage, difficulty getting words out)
-symptoms of psychiatric mental illness
When any abnormality in effect or behavior is discovered
When emotional and cognitive functioning is questioning
Collecting 4 types of patient data - Answer-Complete (total health) database- Complete
health history and full physical
Focused or problem-centered database- Concerns one problem/part of the body
Follow-up database- status of the problem. The problem should be evaluated at regular
and appropriate intervals
Is the prob getting worse or better?
Emergency database-Urgent rapid collection of crucial information
Diagnostic reasoning - Answer-the process of analyzing health data and drawing a
conclusion to identify a diagnosis.
environment - Answer-Privacy (private room, closed curtain)
Know when to talk to adolescents vs to their parents
Do assessments with nudity last
Only give the patient a gown right before the physical examination
Sit at equal length with no distraction
Room at a comfortable temperature
Sufficient lighting
Quiet
4-5 feet between client
Blockers for Communication - Answer--not being attentive
-no fiddling
-look professional
-be impartial
-a nod to express interest/ understanding
-limit reaction to patients answers
-sit facing patient at eye level
