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Exam 2: NU 160 / NU160 (2026–2027 Updated Edition) Mental Health Concepts | Complete Q&A Review | Verified Answers | 100% Accurate Solutions | Grade A – Galen

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…..DLDD Exam 2: NU 160 / NU160 (2026–2027 Updated Edition) Mental Health Concepts | Complete Q&A Review | Verified Answers | 100% Accurate Solutions | Grade A – Galen Q. The nurse is assessing a pt who recently was Dx with a stroke. The pt is very emotional. In what part of the brain did the stroke most likely occur? ANSWERS Limbic system Q. The nurse is caring for a pt in the mental health facility who has a Dx of bipolar disorder. The nurse know that this is because mental health is directly affected by the ANSWERS Neurotransmitters Q. An insufficient amount of the neurotransmitter GABA may result in ANSWERS Anxiety Q. The nurse is using CAGE screening tool. This tool is used for what screen? ANSWERS Problem alcohol use Q. Nurse I performing a mental health assessment. Data collection for mental health assessment begins when the nurse ANSWERS First sees the pt Q. Nurse notices that a pt has difficulty separating relevant from irrelevant information during a conversation. This patient is having difficulty sirh ANSWERS Circumstantiality Q. The nurse is assessing pt stressors. Which tool can be used to identify the degree of stressors pt may be experiencing ANSWERS Holmes social readjustment inventory scale Q. Nurse is planning to teach a group of pt stress reduction exercises to reduce risk of depression. Which population group is at its highest for depression ANSWERS Adolescents Q. The nurse suspects altered thought processes. Which findings may suggest an alter thought process (select all that apply) ANSWERS Problems articulating words Cultural differences Q. The nurse is obtaining a mental health history of a new pt. What should the nurse include in the mental health history? (Select all that apply) ANSWERS Past medical history Pt description of self Q. The nurse is assessing a patient's nutritional status and suspects the patient needs more macronutrients. Which of the following are considered macronutrients? ANSWERS Fats Q. The nurse is teaching a patient the importance of protein for healing. Which foods should the nurse include in the teaching plan? ANSWERS fish Q. The nurse is assessing a patient's dietary intake to help the patient lose weight. What is the easiest way to assess the patient's normal dietary intake? ANSWERS Asking the patient to do a 24-hour dietary recall Q. The nurse suspects that the patient is suffering from malnutrition. Which laboratory test indicates a patient's protein calorie status? ANSWERS Serum albumin Q. The nurse is teaching adult male healthy eating guidelines. How many servings of dairy should the nurse recommend for this patient? ANSWERS 2 to 3 Q. The nurse is assessing an elderly patient's risk of nutritional deficiency. An important risk factor for nutritional deficiency in the elderly is: ANSWERS Decreased ADL Q. In which age group is skipping meals most commonly seen? ANSWERS Adolscents Q. According to the food plan, what represents one serving from the bread, cereal, and grain products group? ANSWERS 1 slice of bread Q. The nurse is working with a patient to develop a nutritional plan for a patient newly diagnosed with diabetes. The nurse assesses what the patient's food preferences are because: ANSWERS food preferences and dislikes have a strong influence on what a person eats. Q. The school nurse is assessing the nutritional status of a healthy adolescent. Which assessment will the nurse include in this assessment? (Select all that apply.) ANSWERS Dietary assessment Biochemical test results Anthropometrics Q. The nurse is performing a skin assessment on a patient in pain. Which skin layer contains sensory fibers that react to touch, pain, and temperature? ANSWERS dermis Q. The nurse is performing a skin assessment and finds that the patient has milia. In which age group would this be an expected finding? ANSWERS newborns Q. A patient is concerned because the dermatologist diagnosed macules all over the skin. The patient asks the nurse what could be causing this? The nurse's best response is: ANSWERS Macules are freckles are considered normal on the skin Q. The nurse is assessing an African-American patient for cyanosis. Cyanosis in dark pigmented skin appears as a(n): ANSWERS Ashen gray color to the skin Q. The nurse is assessing a patient for nail clubbing. Where should the nurse focus the exam? ANSWERS The angle of the nail base Q. A patient comes to the clinic for a skin check. Which finding by the nurse indicates a need to further investigate a lesion? ANSWERS The lesion bleeds easily when it is touched. The nurse is performing a skin check on a patient. In which age group is seborrheic keratosis an expected finding? older adults The nurse is teaching a parent about risk factors associated with the skin for their school-age child. What would the nurse include as the most common cause of skin lesions for this age group? Communicable disease and bacterial infection The nurse is assessing a patient's skin turgor. Skin turgor is assessed by: pinching the skin and watching the skin return to place The nurse knows that the functions of the skin include which of the following? (Select all that apply.) -Sensory input -Protection -Production of vitamin D A patient is complaining of difficulty hearing. Which structure of the ear stimulates the acoustic nerve? ossicle The nurse is assessing a patient's mandible. The area between the sternocleidomastoid muscles and the mandible is anatomically known as the: Anterior triangle The nurse is assessing a patient's optic disc. What instrument would be best for this assessment? The optic disc is viewed with an ophthalmoscope The nurse is aware that the greatest physical variation of ears among individuals of different races is: Consistency and color of cerumen The nurse suspects that a female patient is having trouble with the thyroid when the patient answers yes to which question? "Have you noticed a change in your level of energy?" The nurse is treating a patient for a nosebleed. The patient complains of frequent nosebleeds. What could be a possible cause of the nosebleeds? Snorting cocaine The nurse is assessing a patient for confrontation. The confrontation test assesses: peripheral vision The student nurse is learning how to use the ophthalmoscope. When performing an ophthalmoscopic examination, examine the patient's right: eye with your right eye and the patient's left eye with your left eye. The nurse is documenting in the chart. For documentation purposes, which term is used to describe a head that is of average size and shape? normocephalic The nurse is asking the patient to stick out his tongue and move it back and forth. Which cranial nerve is the nurse testing? Hypoglossal nerve (CN XII) The student nurse is reviewing the pathophysiology of inspiration. The primary muscles of inspiration are the diaphragm and the ____________. external intercostal muscles A patient complains to the nurse of coughing up green phlegm and is having difficulty breathing at rest. The nurse suspects: bacterial pneumonia The nurse assesses a patient who has a costal angle greater than 90 degrees. What is the most likely cause of this finding? COPD The nurse auscultates prolonged expiration with expiratory wheezing and diminished breath sounds while assessing a patient. What does the nurse suspect? asthma The nurse is palpating a patient's chest wall. What can be accomplished with palpation of the chest? Assessment of equal chest expansion The nurse percusses a patient's chest and feels dullness. The nurse suspects which diagnosis? Pneumonia A nurse hears inspiratory and expiratory wheezes bilaterally. What is the meaning of this finding? narrowed airways A nurse hears bronchovesicular sounds in the posterior chest on either side of the spine. This finding indicates: normal finding The examiner notes a diaphragmatic excursion of 4 cm on the right side and 8 cm on the left side. What do these findings mean? The patient may have a pleural effusion. During an assessment, the nurse knows that expected assessment findings in the normal adult lung include the presence of what? (Select all that apply.) Absent voice sounds and hyperresonant percussion tones Symmetric chest Increased tactile fremitus and dull percussion tones Resonant percussion tones Which question is appropriate for a nurse to ask at the beginning of a mental health history "How have you been feeling about yourself?" During a history the patient says that she is so uncomfortable with her life that she wishes that is was over. Which is an appropriate f/u question from the nurse In which ways has your life been uncomfortable During a health history a patient says "stressors? Oh, yeah I have stressors. I got a promotion at work, and with extra income, I'm going to move into a new house. But has that been delayed because my mother is in the hospital and my son is going off to college. To get though this time, I just keep using my support systems, exercising, and meditating." How does a nurse interpret these comments by this pt? Positive coping strategies Which technique does a nurse use to assess the mental status of pts? Have them calculate the change to expect after making a purchase During a sports physical of an 18 year old girl, the nurse asks which questions to collect data about drug use Many teenagers have tried steer drugs. Have you tried any? A patient reports nausea and vomiting, and the nurse observed hand tremors, agitation, and sweating. In view of these findings, which additional cues would the nurse need to collect? When the pt last drank alcohol and how much was consumed The nurse calculates the body mass index of a pt at 31.8. What is the most appropriate action of the nurse Refer to the pt for behavioral interventions for weight loss A man weighs 265 pound and is 6 feet 4 inches tall. Based on these data, how these the nurse classify his weight Class 1 obesity An older woman is 5 feet 2 inches and weights 100 pounds. To best understand her dietary intake, which question is most appropriate? What you eat on a typical day Why does the nurse ask about medications taken as part of a nutritional assessment The absorption and bioavailability of some medications are affected by food A pt reports a lot of unintentional weight loss I've the past 4 months. The nurse measures his height and weight 5 get 11 inches 170 pounds and determines that his body mass index is 22.7. Which action is most appropriate to better evaluate his recent weight loss? Ask, what is your usual body weight A pt has edema and redness of the skin surrounding the. Ail on his right index finger. Which data elicited from his history best explains the condition? He has a new full time job as a dishwasher at a restaurant When examining a 16-year old male pt, the nurse notes multiple pustules and comedowns on the face. The nurse recognizes that increased activity of which cells or glans produce these manifestations Sebaceous glands A patient with darkly pigmented skin has been admitted to the hospital with hepatitis. How does the nurse assess for jaundice in this patient? Inspect color of sclera A patient has multiple solid, red, raised lesions on her legs and groin that she describes as "itchy insect bites." How does the nurse document these lesions? wheals The nurse observes multiple red circular lesions with central clearing that are scattered all over the abdomen and thorax. How does the nurse document the shape and pattern of these lesions? Annular and generalized Which disorder is an example of a vascular lesion? port wine stain A 60-year-old male patient states that he has a sore above his lip that has not healed and is getting bigger. The nurse observes a red scaly patch with an ulcerated center and sharp margins. These findings are commonly associated with which malignancy? Squamous cell carcinoma A 48-year-old woman asks the nurse how to best protect herself from excessive sun exposure while at the beach. Which response would be most appropriate? "Apply a waterproof sunscreen (SPF 15 or higher) to exposed skin surfaces; reapply at least every 2 hours." A patient describes a recent onset of frequent and severe unilateral headaches that last about 1 hour. Based on these symptoms, the nurse suspects which type of headache? Cluster headaches During a physical examination, the nurse is unable to feel the patient's thyroid gland with palpation from an anterior approach. What is the appropriate action of the nurse at this time? Recognize that this is an expected finding A 24-year-old female patient has a 2-day history of clear nasal drainage. Based on these data, which question is the most logical for the nurse to ask? Do you have allergies? A 32-year-old woman has a 4-day history of sore throat and difficulty swallowing. The nurse observes tonsils covered with yellow patches. The tonsils are so large that they fill the entire oropharynx and appear to be touching. How does the nurse document these findings? Enlarged tonsils 4+ with yellow exudate A nurse is obtaining a health history from a 52-year-old male patient with a red lesion at the base of the tongue. What additional data does the nurse specifically collect about this patient? Alcohol and tobacco use While talking with a patient, the nurse suspects that he has hearing loss. Which examination technique is most accurate for assessing hearing loss? Audiometry test Which data from the health history of a 42-year-old man should be evaluated further as a possible risk for hearing loss? "My primary hobby is carpentry work." The nurse examines a patient's auditory canal and tympanic membrane with an otoscope. Which finding is considered abnormal? Yellow or amber color to the tympanic membrane During an eye examination, how does a nurse recognize normal accommodation? The pt pupil dilate when looking towards a distant object How does the nurse assess a patient's consensual reaction? By shining a light into the patient's right eye and observing the pupillary reaction of the left eye What are the characteristics of lymph nodes in patients who have an acute infection? They are enlarged and tender Which technique is used for palpating lymph nodes? Apply gentle pressure over the nodes with the pads of the fingers A nurse suspects a viral infection or upper respiratory allergies when the patient describes the sputum as being which color? clear During inspection of the respiratory system the nurse documents which finding as abnormal? Patient leaning forward with arms braced on the knees A patient has an infection of the terminal bronchioles and alveoli that involves the right lower lobe of the lung. Which abnormal findings are expected? Fever and tachypnea with crackles over the right lower lobe On auscultation of pt lungs, the nurse hears a low pitched, coarse, loud, & low snoring sound. Which term does the. Use use to document this finding? Rhonci A nurse finds the patient's AP diameter of the chest to be the same as the lateral diameter. Based on this finding, what additional data would the nurse anticipate? decreased breath sounds on ausculation How does the nurse palpate the chest for tenderness, bulges, and symmetry? With the palmar surface of fingers of both hands, feels the consistency of the skin over the chest and the alignment of vertebrae Which breath sounds are expected over the posterior chest of an adult? vesicular Narrowing of the bronchi creates which adventitious sound? wheezing A nurse is auscultating the lungs of a healthy female patient and hears crackles on inspiration. What action can the nurse take to ensure this is an accurate finding? Ask the patient to cough then repeat the auscultation. Which finding is often confused as a normal part of the mental health assessment related to the aging process? Anxiety Delirium Depression Which mental health problem would the nurse assess for in a pt who has a heart rate of 120 beats/min and a blood pressure of 180/90 Anxiety A nurse in the emergency department is assessing a patient with a moderate left pneumothorax. What does this nurse expect to find during the respiratory examination? Distant to absent breath sounds over the left chest Which funding would the nurse expect when assessing a pt w/o a mental health disorder? Neutral affect Which pt statement would indicate to the nurse need to complete the alcohol use disorders indemnification test (AUDIT) I missed work twice last month because of a hangover Which assessment datum would cause the nurse to assess further for altered mental status? The pt states the year is 1960 Which question would the nurse ask an adolescent pt when completing a problem based mental health history Have you ever used drugs in the past Have you had difficulty concentrating Have you noticed any change in your eating habits Which concept may impact a pt mental health Stress Anxiety Addiction Cognition Mood and affect Functional ability Which statement describes the reason the nurse would ask a of if they have experienced any behaviors that could indicate a mental health problem Determine the pt past medical history of mental health disorders Which question would the nurse ask to determine if a pt has been experiencing any stress? Have there been any recent changes in your life Which statement guides the nutritional care of the pt while accommodating cultural considerations Herbal medications may interact with prescribed medications Which factor would the nurse include when providing nutritional counseling & weight management to an adolescent with obesity who is expressing concerns about weight Female Genetics High fat diet Ethnicity/race Sedentary lifestyle Which aspect would be included by a nurse conducting a nutritional assessment when concerned over a pts weightloss Assessment of nutrient intake Medication & supplement use Recent growth, weight loss, or weight gain Chronic illness affecting nutritional status or intake Which tool helps the nurse directly assess diet adequacy when conducting an assessment of a pt nutrition Food diary 24-hour recall diet Which method is the nurse using to access dietary intake when asking the pt to list all foods eaten in the last 24 hours Obtains a 24-hour recall Which condition is the most common nutritional concern in the US Obesity Which question would the nurse include during a nutritional assessment related to the present health status of a pt Do you have any chronic likenesses Which assessment would the nurse perform during an examination of the head and face Temporomandibular joint Maxillary and frontal sinus Which pt would the nurse suspect of having chronic obstructive pulmonary Disease based on findings of the nail assessment Nail yellowish in color, nail base angle 175 degrees, boggy nail Base Nurse performs a skin assessment on a pt who requires oxygen therapy with a nasa cannula. Which area will the nurse inspect for skin irritation & breakdown. Nose Ears Which action by a student nurse examining the month, throat, nose, & eyes, of a young child needs correcfion Using a tongue blade initially to examine the mouth & the throat Which core skill would the nurse use to examine a pt skin Inspection Which statement is true regarding assessment of skin turgor Skin turbot can be used to assess hydration status The nurse is reviewing risk factors for melanoma with a pt who was scheduled for an overall skin assessment. Which factors would the nurse include in the discussion Skin type 1 or 2 First degree relative with melanoma History of sever blistering sunburns History of using an indoor tanning devices While assessing a 16 year old female pt, the nurse finds that the pt has excess hair on her face, legs, hands, & Chest. Which term would the nurse use to document this finding Hirsutism Which statement would the nurse use to accurately describe a pt abnormal skin assessment findings charting A dime sized irregularly shaped red area is on the right cheek After examining the nails of a pt, the nurse concludes that the pt has chronic iron deficiency anemia. Which findings supports the nurse conclusion Conclaves shaped, spoon like nails Which technique would the nurse use when assessing a pt with a lesion on the forearm Inspect the area Palpate for swelling Physiologic jaundice is commonly visible in which area of the newborn? Skin Sclerae Gums Which statement by a student nurse about presbycusis indicates effective learning Is is the sensorineural loss that occurs with aging While assessing a pt the nurse suspects the pt has vertigo. Which question would the nurse ask the pt during assessment Do you ever feel like the room is moving around you Nurse is performing an otoscopic examination in an adult pt. What would the nurse do to straighten the pt ear canal during the test Pull pt pinna up & back Which symptom is likely to be seen in a pt with epistaxis Bleeding from anterior nasal septum Which condition does the nurse suspect after observing bright red blood on the pts left eyeball and a round, bright red 1-mm patch over the lateral aspect of the globe Subconjunctival hemorrhage Which cranial nerve may be affected in a pt whose eye does not move to the down and nasal positons Cranial nerve 4 Which assessment would the nurse include during the examination of a young child's head & face ex Inspecting the size & shape of the head Pt reports to the nurse that they are having trouble seeing nearby objects. Which type of response is associated with this type of adaption Accommodation Which assessment finding will the nurse identify in a pt with a barrel chest Anteriorposterior diameter is equal to the transverse diameter Which action would the nurse include when auscultating the anterior chest of a pt for breath sounds Starts the auscultation at the spices in the Supraclsvicilar areas Auscultates & listens for one full respiration in each location Completed then examination by auscultation down to the 12th rib 83 year old pt arrives with their daughter at the ED and the daughter reports the pt has experienced the sudden onset of confusion. A chest x ray confirms suspension of pneumonia. The nurse will provide explanation to the daughter regarding the onset of sudden confusion Adequate oxygenation is critical to neurological function Nurse is planning to work with advanced practice registered nurse as the APRN performs which assessment technique Precision of the thorax for diaphragmatic excursion Young adult pt comes to the ED reporting difficulty breathing. The person has labored breathing & appears anxious. The nurse hears audible wheezing. Pt respiratory rate is 32 breaths/min which disorder does then nurse suspect Asthma Nurse is receiving the change of gift Robert regarding of admitted with bacterial pneumonia. Which datum given in the support will the nurse question Pt has crackles in the left middle lobe Pt who is 65 yes lol old has smoked a pack and a half everyday for 40 years. The nurse will record pt pack year smoking history in which manner 60 pack years Nurse is assigned to care for an older pt admitted with difficulty breathing. Which age related change would the nurse expect to find during the assessment Kyphosis Palpation little expansion, decreased tactile tremors. Percussion hypertesonant sounds Emphysema Nurse is assessing lungs of a pt on the anterior side of the chest. Would the nurse find the highest point of the lung It is found up to 4 cm above the first rib Nurse is caring for a pt who has a fever and a productive cough. How would the nurse expect the sputum of a pt with pneumonia to appear Yellowish-green Nurse starts to count the ribs of a pt from the angle of Louis. Which statement precisely describes the angle of Louis It is the junction of the manubrium and the sternum Which finding would the nurse document as normal when auscultating a pt chest for breath sounds Vesicular breath sounds through the peripheral lung fields During the chest assessment of a pt, which reference line does the nurse note on the posterior chest wall Vertebral line Nurse would monitor for which serious complication for an older adult with kyphosis Decreased expansion of the thoracic wall Which breath sound heard upon auscultation does not the nurse consider normal? Bronchial Vesicular Bronchovesicular Which statement describes a normal feature of the right lung that the nurse would be aware of It has a middle lobe Which finding is a cause for concern after assessing a pt respiration's Intercostal spaces appear to be retracting Nurse is caring for a pt with suspected tracheal obstruction. The pt makes a high pitched, harsh sound on inspiration. Which term would the nurse use to document thisnfidnjng Stridor Which assessment finding will the nurse document for a pt with chronic respiratory disease Pt distal phalanx is clubbed Buddhism nutritional assessment Vegetarian; alcohol avoidance Catholic Nutrition assessment Avoid meat on certain holy data such as Ash Wednesday, Good Friday's and during lent Hinduism nutrition do not consume alcohol, beef, pork, fowl, red colored foods fast ok holy days Islam nutrition No pork or pork products. No alcohol. Judaism nutrition Avoid pork and shellfish; other foods should be kosher; meat and dairy cannot be combined Mormonism nutrition Avoid alcohol and caffeine Seventh day Adventist nutrition Vegetarian diet; animal products eggs, dairy consumed in moderation. Clean meats similar to kosher Fat soluble vitamins A, D, E, K water soluble vitamins B vitamins and vitamin C major minerals calcium, chloride, magnesium, phosphorus, potassium, sodium, sulfur trace minerals minerals essential in nutrition, needed in small quantities daily. iron and zinc are examples Water composes approximately __________ of body weight. 60% nutritional assessment -First, it identifies people who are malnourished or are at risk for malnutrition. -Second, it provides data for designing a nutrition plan to prevent malnutrition. -Third, it establishes baseline data for evaluating nutritional care. Skin assessment findings reflect the overall health, hydration, and nutritional status of the patient. T or F True Skin changes related to aging include melasma, linea nigra, increased sebaceous and cutaneous gland function, and hair loss. T or F F it relates to pregnancy Loss of elastin, collagen, and subcutaneous fat results in decreased resilience, sagging, wrinkling, and increased fragility of the skin during pregnancy. T or F F Assessment of the nails and hair is performed as a part of the __________ assessment. skin ? And cupping are self treatments performed as a cultural practice and home remedy Coining Skin blank exam is red assists pt to identify problematic lesions Self Many skin changes occur with pregnancy and over the Aging process limbic system emotional brain Holmes and Rahe Social Readjustment Scale This is a self-report test to see the amount of possible stressful events in your life that could lead to illness MMSE Cognitive assessment Yesaugage Geriatric depression scale Beck Anxiety Burnt Depression frontal lobe associated with reasoning, planning, parts of speech, movement, emotions, and problem solving HITS Screen interpersonal violence assess nutrition Ht & wt BMI Assess skin, hair, nails, eyes, teeth, mouth Eliminating patterns I&O Supplements Waist hip ratio Eating disorders Fam Hx Surgeries Illnesses Feed & cook Access to food ETOH & drugs Dietary intake Appetite Exercise Occupation Pregnancy Albumin protein in blood; maintains the proper amount of water in the blood Calorie intake Low- associated with mortality Need high protein for wound healing (ex) Elderly Burns Illnesses Prealbumin Dietary intake last several days Hemoglobin and hematocrit o Female: 12-16 hct: 37-47 percent Male: 14-18 hct: 42-52 percent o anemia risks Women are high risk Trauma Hemorrhage Surgery lipid profile, BUN, S.P. HDL, LDL, Triglycerides, BUN creation- kidney function/ hydration Specific gravity-hydration BMI ranges underweight: 18.5 normal: 18.5-24.9 overweight: 25-29.9 obese class 1: 30-34.9 Obese class 2: 35-39.9 Obese class 4: greater than 40 Desirable Body Weight (DBW) Female 5ft equals 100 pounds add 5 pounds per inch over 5 foot Male 5 ft equals 106 pounds add 6 pounds per inch over 5 foot Waist-to-hip ratio (WHR) waist circumference divided by hip circumference Female- 0.8 or less Male- 1 or less Percent IBW actual weight/IBW x 100 nychia Clubbing greater than 160 Milia Acne Kolionychia or spoon nails Nails with a concave shape/ lateral edges Leukonychia White spots on the nail Lanugo fine downy hair of newborn infant Healthy people goal Promote health and reduce chronic disease risk through the consumption of healthful diets and achievement and maintenance of healthy body weights Skin tugor assessment Infant- abdomen Elderly- under clavicle Adults- under forearm Pressing ulcer stage Stage 1- skin intact, red, over bony prominence, non blanching Stage 2- partial thickness- skin loss- superficial Stage 3- full thickness- skin loss- sub Q Stage 4- full thickness- loss with bone or tendon visible Unstageable- wound bed is covered Ecchymosis large bruise petechiae small, pinpoint hemorrhages cherry angioma (vascular lesion) a small blood vessel tumor Early Signs of Melanoma: ABCDEF asymmetry, border, color, diameter, elevation, feeling anterior lobe closed by 18 months Posterior lobe close by 2-3 months PERRLA pupils equal, round, reactive to light and accommodation accommodation the process by which the eye's lens changes shape to focus near or far objects on the retina (close distance) presbycusis age related hearing loss EOM extraocular movement corneal light reflex also known as the Hirschberg test, assesses parallel alignment; have pt look straight ahead, shine light from 12" and look for reflection on corneas in exactly the same position in both eyes; asymmetry indicates deviation in alignment from eye muscle weakness or paralysis cover test examination of how the two eyes work together and is used to assess binocular vision cardinal fields of gaze how to test CN's III, IV, VI Cranial Nerve 2 Optic - vision acuity Cranial Nerve 3 Oculomotor (eye movement) visual field Cranial Nerve 4 Trochlear (eye movement) Cranial Nerve 6 Abducens consensual reaction Shine light in one pupil and they both constrict turbinates Layers of bone within the nasal cavity.

Meer zien Lees minder
Instelling
NU 160
Vak
NU 160

Voorbeeld van de inhoud

…..DLDD\\\\\\\
Exam 2: NU 160 / NU160 (2026–2027 Updated Edition)
Mental Health Concepts | Complete Q&A Review |
Verified Answers | 100% Accurate Solutions | Grade A –
Galen

Q. The nurse is assessing a pt who recently was Dx with a stroke. The pt is very emotional. In what part of
the brain did the stroke most likely occur?


ANSWERS
Limbic system




Q. The nurse is caring for a pt in the mental health facility who has a Dx of bipolar disorder. The nurse
know that this is because mental health is directly affected by the


ANSWERS
Neurotransmitters




Q. An insufficient amount of the neurotransmitter GABA may result in

ANSWERS
Anxiety




Q. The nurse is using CAGE screening tool. This tool is used for what screen?

ANSWERS
Problem alcohol use



1

,Q. Nurse I performing a mental health assessment. Data collection for mental health assessment begins
when the nurse


ANSWERS
First sees the pt




Q. Nurse notices that a pt has difficulty separating relevant from irrelevant information during a
conversation. This patient is having difficulty sirh


ANSWERS
Circumstantiality




Q. The nurse is assessing pt stressors. Which tool can be used to identify the degree of stressors pt may be
experiencing


ANSWERS
Holmes social readjustment inventory scale




Q. Nurse is planning to teach a group of pt stress reduction exercises to reduce risk of depression. Which
population group is at its highest for depression


ANSWERS
Adolescents




2

,Q. The nurse suspects altered thought processes. Which findings may suggest an alter thought process
(select all that apply)


ANSWERS
Problems articulating words
Cultural differences




Q. The nurse is obtaining a mental health history of a new pt. What should the nurse include in the mental
health history? (Select all that apply)


ANSWERS
Past medical history
Pt description of self




Q. The nurse is assessing a patient's nutritional status and suspects the patient needs more
macronutrients. Which of the following are considered macronutrients?


ANSWERS
Fats




Q. The nurse is teaching a patient the importance of protein for healing. Which foods should the nurse
include in the teaching plan?


ANSWERS
fish




3

, Q. The nurse is assessing a patient's dietary intake to help the patient lose weight. What is the easiest way
to assess the patient's normal dietary intake?


ANSWERS
Asking the patient to do a 24-hour dietary recall




Q. The nurse suspects that the patient is suffering from malnutrition. Which laboratory test indicates a
patient's protein calorie status?


ANSWERS
Serum albumin




Q. The nurse is teaching adult male healthy eating guidelines. How many servings of dairy should the
nurse recommend for this patient?


ANSWERS
2 to 3




Q. The nurse is assessing an elderly patient's risk of nutritional deficiency. An important risk factor for
nutritional deficiency in the elderly is:


ANSWERS
Decreased ADL




Q. In which age group is skipping meals most commonly seen?

ANSWERS
Adolscents


4

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