Exam 4: NU 160/NU160 Version 2 (2026–2027 Update) Mental Health Exam Prep Kit | Real Q&A + Verified Solutions | 100% Accuracy | A Grade – Galen

…..DLDD Exam 4: NU 160/NU160 Version 2 (2026–2027 Update) Mental Health Exam Prep Kit | Real Q&A + Verified Solutions | 100% Accuracy | A Grade – Galen Q. Case 1: Lindsey filed into the party drunk and continued to drink throughout the night. She flirted with several people, laughing and giggling with everyone she talked to. Two guys noticed her sensual vibes. Twice during the evening she diapered for almost half an hour, each time with different people. After a heated argument with one of them, because he took forever to get her a drink, she locked herself into the bathroom and attempted to swallow a bottle of Excedrin. Her friends encourage her to go home, but she was afraid to be alone in her apartment. ANSWERS Borderline Personality Disorder Q. Case 2: An administrative assistant has recently been terminated because of her inability to complete work projects on time. According to her, they were not in the correct format and she had to revise them 5 times, which led to the delay. This has happened before but she feels that she is not given enough time. This has also led to her being late to meetings and receiving poor performance reviews by her boss. ANSWERS Obsessive Compulsive Disorder Q. Case 3: Richard danced his way into a party and immediately became the center of attention. With grand gestures of his arms and dramatic displays of emotion, he bragged about his career as an actor in a local theater group. During a private conversation, a friend asked about the rumors that he was having some difficulties in his marriage. In an outburst of anger, he denied any problems and claimed that his marriage was as amazing and romantic as ever. Shortly thereafter, while drinking his second martini, he fainted and had to be taken home. ANSWERS Histrionic Disorder Q. Case 4: A 28-year-old social media influencer is rushed into the ER after a car accident. She does not let the residents operate on her and request the chief of trauma and plastic surgery because her face and body are vital to her career. She makes several calls, posts and texts in the ER to stay on top of her soicals. During one of her phone calls, she became irate staring none of the nurses were catering to her needs or interested in her future success. ANSWERS Narcissistic Disorder Q. Case 5: A 38-year-old women, named Jessica, dresses in a space suit every Wednesday and Friday. She has computers set up in her basement that detect the precise time of the next alien invasion. The super sonic negative forces in the other rooms of her house she finds to be unsettling to her psychic- soul- spot. She has no evidence of auditory or visual hallucinations. ANSWERS Schizotypal Disorder Q. Case 6: A 28-year-old unemployed male has been accused of killing 3 senior citizens after robbing them. He is surprisingly charming in the interview. However when cops ask him how he felt after killing his victims, he barely suppresses an urge to laugh out loud and then denies any responsibility: " those old folks knew they were going to die soon, so what is the big deal, I was helping them out." In his adolescents, he was arrested several times for stealing cars and assaulting other kids. ANSWERS Antisocial Disorder Q. Case 7: Before entering, Kathy watched the party for several minutes form outside through the window. Once she went in, she seemed very uncomfortable. When people tried to be nice to her, she looked worried and distrustful. People quickly became uncomfortable with her habit of finding fault with every little thing someone said or did. She seemed to be picking fights with people. She did not stay at the party for very long. ANSWERS Paranoid Disorder Q. Case 8: Bernard is never invited to parties. No one really knows him very well because he rarely talks. In fact, he spends most of his time alone at home reading. While at work he isolates himself in the lab for most of the day and has no friends, according to his coworkers. He expresses no desire to make friends and is content with his single life. ANSWERS Schizoid Disorder Q. A nurse is assessing the client for manifestations of anorexia nervosa. Which of the following findings should the nurse expect? Select all that apply: A. client has soft, un-pigmented hair on arms B. client comments that they are too thin and need to gain weight C. client reports preoccupation with thoughts about food D. client reports consuming around 600 calories each day E. client hair appears brittle and thin F. client voices being too tired and lacks interests in daily workouts at the gym ANSWERS A. C. D. E. Q. A nurse is caring for a client who was recently diagnosed with somatic symptom disorder. The client says to the nurse "I don't understand, they can't find anything medically wrong with me. I guess I will never feel better." Which of the following responses is the most therapeutic? A. "Lets focus on the physical symptoms that you have" B. "Although there isn't a cure for this disorder, I am sure you will feel better someday." C. "Why do you feel like you will never get better? Do you not have confidence in the medical team?" D. "We will work with you to help you develop ways to manage your symptoms that are caused by the disorder." ANSWERS D. Q. A nurse is caring for a client who has a dissociative disorder. Which of the following actions should the nurse take first? A. teach the client grounding techniques B. establish rapport with the client C. administer a benzodiazepine to the client D. educate the client about their disorder ANSWERS B. Q. Some obese individuals take amphetamines to suppress appetite and help them lose weight. Which is an adverse effect associated with use of amphetamines that makes this practice undesirable? a. Bradycardia b. Amenorrhea c. Tolerance d. Convulsions ANSWERS C Q. The Maudsley approach to treatment of adolescents with anorexia nervosa advances which fundamental concept? a. Family should be actively involved in each phase of treatment. b. Parents should be prohibited from involvement in helping their child eat more because there are often control issues. c. Adolescents need to work on developing healthy self-identities before they can begin to gain weight. d. Individual psychotherapy is the most effective treatment for adolescents with anorexia nervosa. ANSWERS A Q. A client has sought help for their concern that they are binge eating, and the client believes it has "gotten out of control." The client asks the nurse what can be done to help them. Which is the most accurate response? a. "There are no recognized treatments for binge eating disorder." b. "Some medications and psychological treatments that have demonstrated effectiveness in reducing binge eating behaviors." c. "The primary problem is obesity. I can help you set up a calorie-restricted diet." d. "Medications can help with weight loss, but there are no medications effective for reducing binge eating." ANSWERS B Q. Which physical manifestations would you expect to assess in a client with anorexia nervosa? a. Tachycardia, hypertension, hyperthermia b. Bradycardia, hypertension, hyperthermia c. Bradycardia, hypotension, hypothermia d. Tachycardia, hypotension, hypothermia ANSWERS C Q. Which medication has been used with some success in clients with bulimia nervosa? a. Lorcaserin (Belviq) b. Diazepam (Valium) c. Fluoxetine (Prozac) d. Carbamazepine (Tegretol) ANSWERS C Q. A client is hospitalized on the psychiatric unit with a history and current diagnosis of bulimia nervosa. Which symptoms would be congruent with this client's diagnosis? a. Binging, purging, obesity, hyperkalemia b. Binging, purging, normal weight, hypokalemia c. Binging, laxative abuse, amenorrhea, severe weight loss d. Binging, purging, severe weight loss, hyperkalemia ANSWERS B Q. A 14-year-old client has just been admitted to the psychiatric unit for anorexia nervosa. They are emaciated and refuses to eat. What is the primary nursing diagnosis for this client? a. Complicated grieving b. Imbalanced nutrition: Less than body requirements c. Interrupted family processes d. Anxiety (severe) ANSWERS B Q. The nurse is caring for a client who has been hospitalized with anorexia nervosa and is severely malnourished. The client continues to refuse to eat. What is the most appropriate response by the nurse? a. "You know that if you don't eat, you will die." b. "If you continue to refuse to take food orally, you will be fed through a nasogastric tube." c. "You might as well leave if you are not going to follow your therapy regimen." d. "You don't have to eat if you don't want to. It is your choice." ANSWERS B Q. A hospitalized client with bulimia nervosa has stopped vomiting in the hospital and tells the nurse they are afraid they're going to gain weight. Which is the most appropriate response by the nurse? a. "Don't worry. The dietitian will ensure you don't get too many calories in your diet." b. "Don't worry about your weight. We are going to work on other problems while you are in the hospital." c. "I understand that you are concerned about your weight, and we will talk about the importance of good nutrition; but for now, I want you to tell me about your recent invitation to join the National Honor Society. That's quite an accomplishment." d. "You are not fat, and the staff will ensure that you do not gain weight while you are in the hospital, because we know that is important to you." ANSWERS C Q. A client presents in the emergency department with complaints of suicidal ideation. The following data is collected by the nurse. Which assessment findings suggest that bulimia nervosa might be a health problem? (Select all that apply.) a. Parotid glands appear enlarged. b. Teeth have a "moth eaten" pattern of tooth decay. c. Client reports taking laxatives daily. d. Client's weight is within the expected range. ANSWERS A,B,C,D Q. A client diagnosed with BPD manipulates the staff in an effort to fulfill their own desires. All of the following may be examples of manipulative behaviors except: a. Refusal to stay in room alone, stating, "It's so lonely." b. Asking the nurse for cigarettes after 30 minutes, knowing that the assigned nurse has explained the client must wait 1 hour. c. Stating to the nurse, "I really like having you for my nurse. You're the best one around here." d. Making superficial cuts to their arms after discussing discharge plans with physician. ANSWERS A Q. A client on the psychiatric unit has a diagnosis of antisocial personality disorder. Which characteristic is consistent with this diagnosis? a. Lack of guilt for wrongdoing b. Insight into own behavior c. Ability to learn from past experiences d. Compliance with authority ANSWERS A A nurse on the psychiatric unit documents that the client is using "splitting" behaviors with staff. This should be interpreted to mean that the client is exhibiting what behavior? a. Trying to keep the staff away from other clients b. Characterizing staff members as either all good or all bad c. Having brief psychotic episodes d. Manifesting two or more distinct subpersonalities when communicating with staff B According to researchers, which is a common theme in the health history of the client with BPD? a. Autism b. Attention deficit-hyperactivity disorder c. Positive and fulfilling interpersonal relationships d. Early childhood trauma D Which behavioral pattern is characteristic of individuals with narcissistic personality disorder? a. Overly self-centered and exploitative of others b. Suspicious and mistrustful of others c. Rule conscious and disapproving of change d. Anxious and socially isolated A Which behavioral pattern is characteristic of individuals with schizoid personality disorder? a. Belittling themselves and their abilities b. A lifelong pattern of social withdrawal a. Suspiciousness and mistrust of others d. Overreacting inappropriately to minor stimuli B A client with a diagnosis of BPD often exhibits alternating clinging and distancing behaviors. Which is the most appropriate nursing intervention for the client with this type of behavior? a. Encourage the client to establish trust in one staff person with whom all therapeutic interaction should take place. b. Secure a verbal contract from the client to discontinue these behaviors. c. Withdraw attention if these behaviors continue. d. Rotate staff members who work with the client so that the client will learn to relate to more than one person. D A client diagnosed with antisocial personality disorder approaches the nurse and says "You're so cute, are you married?" Which is the most appropriate response by the nurse? a. "I'm married but that's none of your business." b. "Let's talk about your love life instead." c. "Thank-you so much for the compliment but I'm married." d. "Our relationship is strictly professional. It's not appropriate for us to have that kind of discussion." D A client with BPD reports to the nurse that they are having abdominal pain and is requesting pain medication. Which action by the nurse is a priority? a. Explore alternative pain management strategies b. Confront the client about their manipulation to try to get drugs c. Assess the client's pain in more detail d. Set limits on the client's attempts to cling to the nurse C A male client with antisocial personality disorder was found on the bed in a female client's room. When instructed to leave the room, the client states, "I'm sick of you telling me what I can and can't do. If I want to carry on a relationship with one of these ladies, it's my right. I'll do exactly as I please!" Which action by the nurse is a priority at this point? a. Reassure the client that he will have plenty of opportunities with women after he is discharged. b. Reinforce the rules of the treatment program that all clients are expected to follow. c. Escort the client to a seclusion room. d. Establish a trusting relationship by telling the client that an exception will be made just this once. B Which symptom profiles would you expect when assessing a client with somatic symptom disorder? a. Multiple somatic symptoms in several body systems b. Fear of having a serious disease c. Loss or alteration in sensorimotor functioning d. Belief that their body is deformed or defective in some way A Which ego defense mechanism describes the underlying psychodynamics of somatic symptom disorder? a. Denial of depression b. Repression of anxiety c. Suppression of grief d. Displacement of anger B Nursing care for a client with somatic symptom disorder should focus on helping the client to achieve which goal? a. Eliminate stressors. b. Discontinue focusing on numerous physical complaints. c. Take medication only as prescribed. d. Learn more adaptive coping strategies. D A client diagnosed with somatic symptom disorder, states, "My doctor thinks I should see a psychiatrist. I can't imagine why he would make such a suggestion." What is the most common basis for the client's statement? a. Lack of trust in the physician b. Lack of understanding about the correlation of symptoms and stress c. Lack of understanding about the role of a psychiatrist d. Lack of financial resources B What is the ultimate goal of therapy for a client with DID? a. Integration of the identities into one cohesive personality b. The ability to switch from one identity to another voluntarily c. The ability to select one personality as the dominant self the dominant self d. Recognition that the various identities exist A The ultimate goal of therapy for a client with DID is most likely achieved through which intervention? a. Crisis intervention and directed association b. Psychotherapy and hypnosis c. Psychoanalysis and free association d. Insight psychotherapy and dextroamphetamines B Which manifestations would be consistent with the diagnosis of illness anxiety disorder? a. Complains of a multitude of incapacitating physical symptoms b. Presents with pseudoseizures or pseudocyesis c. Takes substances to induce vomiting in order to convince the nurse that of the need for treatment d. Expresses persistent fears of having life-threatening disease D A client diagnosed with somatic symptom disorder tells the nurse about a pain in their side. The client says they have not experienced it before. Which is the most appropriate response by the nurse? a. "I don't want to hear about another physical complaint. You know they are all in your head. It's time for group therapy now." b. "Let's sit down here together, and you can tell me about this new pain you are experiencing. You'll just have to miss group therapy today." c. "I will report this pain to your physician. In the meantime, group therapy starts in 5 minutes." d. "I will call your physician and see if he will order a new pain medication for your side. The one you have now doesn't seem to provide relief. Why don't you get some rest for now?" C A client with a history of childhood physical and sexual abuse was diagnosed with dissociative identity disorder (DID) 6 years ago and has been admitted to the psychiatric unit following a suicide attempt. What is the primary nursing diagnosis for this client? a. Disturbed personal identity related to childhood abuse b. Disturbed sensory perception related to repressed anxiety c. Impaired memory related to disturbed thought processes d. Risk for suicide related to unresolved grief D In establishing trust with a client diagnosed with dissociative identity disorder, the nurse should use which intervention? a. Tell the client that their personality states are related to severe childhood trauma and ask them to elaborate. b. Listen nonjudgmentally and respond empathetically when the client transitions to different personality states. c. Ignore communication that appears to be that of another personality. d. Explain to the client that they must remain in their primary identity state while communicating with the nurse. e. All of the above. B When assessing a client diagnosed with narcissistic personality disorder, the nurse expects to identify which characteristic behavior? A. Odd beliefs and magical thinking B. Grandiose sense of self-importance C. Submissive and clinging behaviors D. Pattern of intense and chaotic relationships B. Grandiose sense of self-importance A client diagnosed with a personality disorder is cold, aloof, and avoids others on the unit. The nurse recognizes that this behavior is symptomatic of which personality disorder? A. schizoid personality disorder B. Antisocial personality disorder C. Boderline personality disorder D. Dependent personality disorder A. Schizoid personality disorder A client diagnosed with borderline personality disorder is admitted to a psychiatric unit. Which behavior pattern would the nurse expect to observe? A. Social isolation B. Bizzare speech patterns C. Suspicious of others D. Generates conflict among the staff D. Generates conflict among the staff In assessing a client diagnosed with borderline personality disorder, which characteristic would the nurse expect to observe? A. Controlled anger B. Stable and satisfactory relationships C. Little tolerance for being alone D. Predictability C. Little tolerance for being alone An individual with a history of antisocial personality disorder was arrested for driving under the influence of alcohol and causing a serious car accident. Which comment on this behavior would be expected? A. "I just don't remember doing it" B. "I am really sorry about all the people I've hurt" C. "Its not my fault" D. "I am too ashamed to talk about it" C. "its not my fault" Which is characteristic of the diagnosis of anorexia nervosa? A. Healthy family relationships B. Obsession with weight gain C. Disregard for the feelings of others D. Body image disturbance D. Body image disturbance Which assessment finding would the nurse expect in clients diagnosed with bulimia? A. They will be highly motivated to seek help B. They are below normal weight C. They binge when they experience hunger D. They are within their normal weight range D. They are within their normal weight range A client is 5 feet 8 inches tall and weighs 105 pounds. The client has been taking laxatives daily and self-induces vomiting after eating. Which is the priority nursing diagnosis for this client? A. Imbalanced nutrition, less then body requirements B. Disturbed body image C. Ineffective denial D. Low self-esteem A. Imbalanced nutrition, less then body requirements A client experiencing lower extremity paralysis is admitted to a medical unit. Extensive tests confirm disability but rule out any underlying organic pathology. The nurse concludes that this is most suggestive of which disorder? A. Malingering B. Conversion Disorder C. Illness anxiety disorder D. SOmatic symptom disorder B. Conversion Disorder A client is experiencing pain that has no organic etiology. This pain allows the client to avoid going to work at a job that he hates. What best describes what this client is experiencing? A. Secondary gain B. Altered social interaction C. Disturbed though process D. Primary gain D. Primary gain According to psychodynamic theory, which primary defense mechanism would the nurse expect to find in a client with dissociative amnesia? A. Repression B. Sublimation C. Displacement D. Suppression A. Repression When working with a client diagnosed with a somatic symptom disorder, which is the most appropriate nursing action? A. Focus on the physical symptoms B. Gradually minimize time focusing on the physical symptoms C. Always meet the clients dependency needs D. Avoid discussing social and personal problems B. Gradually minimize time focusing on the physical symptoms A nurse is discussing the factors for somatic symptom disorder with a newly licensed nurse. Which of the following risk factors should the nurse include? A. Anxiety disorder B. Childhood trauma C. Obesity D. 65 years and older E. Coronary artery disease A. Anxiety disorder B. Childhood trauma A nurse is reviewing the chart of a client who has conversion disorder. Which of the following findings should the nurse identify as placing the client at risk for conversion disorder? A. Retirement 1 year ago B. History of migraine headaches C. Death of a child 2 months ago D. Resent weightless of 30 pounds C. Death of a child 2 months ago A nurse is assessing a client who has illness anxiety disorder. Which of the following are expected for this disorder? A. Obsessive thoughts about disease B. History of childhood abuse C. Depressive disorder D. Narcissistic personality E. Avoidance of healthcare providers A. Obsessive thoughts about disease B. History of childhood abuse C. Depressive disorder E. Avoidance of healthcare providers A nurse is developing a plan of care for a client who has conversion disorder. Which of the following actions should the nurse include? A. Discuss alternative coping strategies with the client B. Encourage the client to spend time alone in their room C. Allow the client unlimited time to discuss physical manifestations D. Monitor the client for self-harm once per day A. Discuss alternative coping strategies with the client A nurse is counseling several clients. Which of the following client statements should the nurse identify as expected for factitious disorder imposed on another? A. "I know that my abdominal pain is caused by a malignant tumor" B. "I needed to make my child sick so that someone else would take care of them for a while" C. "I had to pretend I was injured in order to get disability benefits" D. "I became deaf when I heard that my partner was having an affair with my best friend" B. "I needed to make my child sick so that someone else When teaching the breast self-examination, you would inform the woman that the best time to conduct breast self-examination is: on the 4th to 7th days of the menstrual cycle. a male patient presents to the clinic with a complaint of a hard, irregular, nontender mass on his chest under the areola. Upon examination, the nurse notes that the mass is immobile and suspects carcinoma gynecomastia may occur in an older male secondary to testosterone deficiency When examining the breast of a 75 year old woman the nurse would expect to find which of the following? a grannular feel to the breast tissue it is important to examine the upper outer quadrant of the breast because it is where most breast tumors develop a 23 year old nulliparous woman is concerned that her breasts seem to change in size all month long and they are very tender around the time she has her period. The nurse should explain to her that cyclical breast changes are normal A patient with benign breast condition is likely to q have it resolve after menopause. THe nurse palpates a fine, round, mobile, nontender, nodule and suspects that it is a fibroadenoma Peau d' orange appearance is highly suggestive of what? breast cancer THe correct position in which to place the patient to palpate the breats is supine with arm over head when performing an abdominal assessment, what is the correct sequence? inspection, auscultation, precussion, palpation A patient reports changes in bowel pattern. What is the best question to determine normal bowel habits? What was your bowel pattern before you noticed the change? When percussing the abdomen, the nurse notes a dullness at the anterior right costal margin at the right midclavicular line. Which organ is most likely involved? Liver What percussion sound is heard over most of the abdomen? tympany A patient with a history of kidney stones presents with complaints of pain, hematuria, and nausea with vomitting. The nurse documents this finding as a bruit of what? Right iliac artery A patient with a history of cirrhosis tells the nurse that his abdomen seems to be getting larger and that he has gained 9.7 kg(20 lbs) in the past 6 months. How will the nurse determine whether the abdominal enlargement is from accumulation of fluid or fat from the weight gain? Percuss the abdomen for shifting dullness A patient with tympanic abdomen complains of pain in the RUQ. Which sign would the nurse expect to be positive? Murphy sign Which assessment technique best confirms splenic enlargement? Percussion along the left MAL spleen and gentle palpation When documenting a finding over the stomach, the nurse most accurately identifies the region as? epigastric Mr. Brown was playing soccer and hurt his right knee. It appears to be swollen. What is the first assessment you should make? Compare the swollen knee with the other knee. Mrs. Johnson, a transcriptionist, reports pain and burning in her right hand. What assessment procedures should the nurse perform next? Phalen and tinel tests Which of the following assessment tasks can you appropriately delegate to an unlicensed care provider? Height, weight, and vital signs When doing an assessment of the spine of an older adult, you can expect to see which variation? Kyphosis The patient's muscle tone is hypertonic so the muscles are stiff and the movements are awkward. The nurse documents these findings as: spasticity To correctly document the ROM in the fingers is full and active, the nurse writes that the patient can... make a fist, spread and close fingers, and do finger thumb oppositions. You note that an adolescent has uneven shoulder height. To differentiate functional from structural scoliosis, you ask the patient to bend forwards at the waist while you palpate the spine. A patient reports that a previous right hip replacement is suddenly painful. Which hip assessment technique should you omit? Adduction A young adult marathoner reports of right foot third metatarsal pain (6/10) and swelling for more than 4 weeks. An x-ray was ordered, and it did not show abnormal findings. Which of the following imaging might the nurse expect the physician to order? MRI A man had a motor vehicular accident and fractured his right ankle. He was transferred from the emergency department to the orthopedic nursing unit for further observation and possible surgery in the next 12 hours. What is the priority nursing assessment of the admitting orthopedic nurse? Capillary refill distal to the injury of the right ankle A clinical nurse is assessing a patients knowledge and understanding of bone health and maintenance. Which of the following responses of the patient indicates adequate understanding to maintain musculoskeletal health? I will take calcium supplementation and vitamin D as prescribed. Which of the following patients is at highest risk for osteoporosis? A middle age woman of lower socioeconomic status who is a heavy smoker and drinks alcohol six times times a week Use of the GCS provides relatively objective assessment of LOC, The three functions assessed are.... verbal response, eye opening, and motor response A patient with a head injury and increasing ICP is likely to have which assessment finding? Decrease LOC and sluggish pupil The chart states that a 62 yr-old woman has a stroke in the right parietal area of the brain. The nurse expects to note ... Weakness in the left arm The nurse performs BP screening at the local community center. As part of the health promotion intervention, the nurse also discusses the following risk factors for stroke high BP, diet high in fat, and smoking If the great toe extends upward and the other roes fan out in response to stroking the lateral aspect of the sole of the foot, this is documented as ..... babinski sign A 26 year old man was in a motor vehicle accident and suffered a complete spinal cord injury to L3. The nurse assesses the patient for loss of motor function in the legs a patient in a nursing home was admitted with a diagnosis of dementia. He started a fire because he was cooking at home and forgot that he left a pan on the stove. The nursing diagnosis that is highest priority is: risk for injury While the nurse performs formal patient assessment, assistive personnel often observe changes when obtaining vital signs or assisting patients with ADLs. When discussing care for a patient with back pain, the nurse should particularly alert the assistant to watch for.... bowel/bladder incontinence A 47 year old woman states she is having vertigo and some difficulty with balance. The nurse should assess: the whisper test Of the following changes, which is the earliest sign of progressing brain herniation that originates in the cerebral hemisphere? altered mentation A patient undergoing a neurological assessment fears a serious diagnosis. Which action by the nurse will best ensure that the patient will comply with the assessment process? Treat the patients concerns and fears with both sensitivity and empathy Which nursing actions are associated with conducting a Glasgow Coma Scale assessment on a patient who has fallen and sustained a possible brain injury? Ask the patient to identify where he or she is. Request that the patient squeeze the nurse hand. Observe which stimuli cause the patient to open eyes. An older patient reports feeling dizzy right before falling. Which action by the nurse indicates an understanding of how dizziness can be triggered? Assess the patients blood pressure. Review the patients medical history for previous head injuries. Ask, "had you been taking any nonprescription medications before the fall?" Which nursing actions would be effective when managing an older adult patients risk for injury related to falling? Encourage the patient to wear prescription glasses. PResent the patient with fluids regularly throughout the day. Offer to take the patient to the toilet every 2-3 hrs. Measure the patients blood pressure both when sitting and upon standing. An older adult patient who lives alone is hospitalized after falling and sustaining a broken arm. Which nursing action will best determine whether the patient is experiencing any cognitive dysfunctions that may have contributed to the fall? Administer an assessment tool such as the Mini-Cog. An older adult patient has fallen and sustained a bruise to the forehead. Although there appears to be no significant injury, the family is concerned when the provider orders a mini-cog assessment and asks, "why are you testing her memory and mental abilities?" Which explanation best meets the familys expressed needs? Your mothers fall may have hurt the frontal lobe of her brain. That is the part that controls memory, reasoning, and judgement. The nurse is reviewing patient data from a neurological assessment and notes that the patients history includes several recent falls.Which nursing actions will the nurse take immediately to address the patients risk for injury? Implement the facilities universal fall percautions During a routine visit, an older patient shares that they recently had trouble remembering things. little things like where he put his keys. Which interview question will the nurse ask to best identify a possible physical cause for the lapse of memory? Have you ever had any kind of head injury during your lifetime? WHich nursing actions demonstrates an understanding of the components required when conducting the objective portion of a neurologic assessment? Evaluate CN X1 function by asking the patient to shrug the shoulders. Test for tactile discrimination using a door key. A patient undergoing a neurological assessment fears a serious diagnosis. WHich action by the nurse will best ensure that the patient will comply with the assessment process. Treat the patients concerns and fears with both sensitivity and empathy Which statement by a patient would cause the nurse to suspect that a pattern of falling exists? I fell twice when i was visiting my daughter 2 months ago. Mrs. Jacobson was prescribed raloxifene hydrochloride 18 months ago. She is concerned the dizziness she felt just before she fell is a result of the medication. How does the nurse best address her concerns? Assure her that dizziness is not one of the recognized side effects of that medication. A patient has reported dizziness that has been associated with orthostatic hypotension. What information will the nurse provide to the patient that is directly associated with this condition? Dehydration can be a trigger for the dizziness. To assess an adult patient suspected of experiencing increased intracranial pressure (ICP), the nurse will implement which intervention? Check pupillary activity The nurses patient, Edith Jacobson, is being monitored after a fall that resulted in a fractured hip. Her initial assessment included a Glasglow Coma Scale assessment that showed she had no observable deficiencies involving consciousness. Following the providers orders she is being monitored with the administration of the Glasgow Coma Scale every 4 hours. When the current assessment indicates that the patient has scored a 14, what will the nurses initial response be? Document the latest Glasgow Coma Scale results as a 14. An older adult is being prepared for discharge to her daughters home after completing rehabilitation following surgery to repair a hip fracture. What information will the nurse include in discharge teaching to best help minimize the patients risk for falls? Sit down and rest when feeling dizzy. Use walking device to help with proper balance. Turn on lights at night when getting out of bed to go to the bathroom. Drink enough fluids to keep your urine pale and clear. An older adult patient is being assessed for risk for falls. Which statements by the patient would the nurse identify as risk factors? I celebrated my 81st birthday last month. My cataract surgery is scheduled in 6 weeks. Im less depressed since ive moved in with my daughter. Ive started to have some trouble getting to the bathroom in time. A patient who fell and hit her head and fractured her femur is scheduled for surgery in the morning. The patient has had a complete neurologic assessment and is currently in stable condition. How will the nursing staff best monitor the patients neurologic status? Perform a neurologic check every 4 hours. What suggestions will the nurse include in the education materials regarding falls prevention at home for an older adult with a history of falls? Keep floors clear of paper clutter. Keep halls and stairs well lighted. Wear rubber soled shoes. Store often used items on shelves that are at waist level. What behavior would the nurse document as lethargy related to Mrs. Jacobsons level of consciousness? Remains awake only long enough to answer questions. The nurse is assessing a patients gait. Which factors should the nurse observe as the patient ambulates in the room? Base of support Stride Arm swing Posture The nurse is assessing a patients joints. What should the nurse include in this assessment? Color Size Symmetry The nurse is completing passive ROM excersizes and bends the patients foot so that the toes point upward. Which skeletal muscle movement has the nurse performed? Dorsiflexion The nurse is assessing a patient for fall risk. Which factors would place the patient at a higher risk for falls? Depression Gait or balance impairment Use of more than four prescription medications The nurse is assessing a patients ROM and notes a limitation in the movement of the elbow joint. Which tool would the nurse use to measure the degree of movement in the joint? Goniometer The nurse is completing a health history on a patient reporting musculoskeletal pain. Which questions would be appropriate for the nurse to include in the interview? Have you experienced any previous injuries to your joints? Do you exercise regularly? What type of job do you have? Have you had any recent weight gain? What medications are you currently taking? Mrs. Russel asks the nurse "what is the purpose of these passive ROM exercises? I can move my own arms and legs. What is the correct response by the nurse? Passive ROM exercises will help you to maintain mobility in your joints. The nurse is assessing flexion in Mr. Russels hip. What instructions would the nurse give to Mr. Russel to complete this assessment? Bend you knee to you chest, and then pull it against your abdomen. The nurse is completing ROM on Mr. Russel. What movements would the nurse expect to complete at the elbow joint? Flexion Extension supination pronation The nurse is educating Mr. Russel on the effects of prolonged immobility. What physiologic changes would the nurse describe to Mr. Russel? Decreased muscle protein synthesis Increased muscle catabolism Decreased muscle mass Bone demineralization The nurse is assessing Mr. Russels medications. Which medications would place Mr. Russel at a higher risk for falls? Merformin Losartan Chlorthalidone The nurse is using the Morse fall scale to determine Mr. Russels fall risk. What variables will the nurse assess by using this tool? History of falls Presence of IV Secondary diagnosis The nurse is educating mr. russel on how to prevent falls. Which statement, if made by the patient, indicates that he understood the teaching? I should press my call light when i want to get out of bed. The nurse is caring for Mr. Russel, who is recovering from a stroke and has mild left-sided hemiplegia. What would the nurse include in the plan of care? Perform passive ROM exercises Encourage the patient to set realistic, short term goals. The nurse is assessing the muscle strength in Mr. Russels left hand and notes active motion against some resistance. How would the nurse document this finding? 4 The nurse is preparing to conduct an abdominal assessment on a patient admitted to the medical surgical unit. Which question should the nurse ask the patient prior to conducting the assessment? Can you please empty your bladder before we begin The nurse is assessing a patients bowel sounds. In which quadrant should the nurse being the assessment? RLQ The nurse is performing a visual assessment of a patients abdominal area. What would the nurse include as part of inspection? Coloration Contour Symmetry THe nurse in interviewing a patient who is reporting chronic abdominal pain. WHat questions would be appropriate for the nurse to include in the nursing health history? Do you experience indigestion? Are you having any nausea or vomitting? Have you noticed an increase or decrease in your appetite? The nurse understands that which structures are located in the left upper quadrant of the abdomen? Pancreas (body and tail) Spleen Stomach The nurse is assessing bowel sounds. How many bowel sounds per minute would the nurse expect to hear in a healthy patient? 5 to 30 The nurse is completing an abdominal assessment on a patient who is one day postoperative. The nurse hears no bowel sounds in the left upper quadrant. How long should the nurse auscultate to determine that bowel sounds in that quadrant are absent? 5 minutes Mr. Hayes asks the nurse why he can only have clear liquids. What is the appropriate repsonse by the nurse? Because your bowels will be sluggish after surgery, this diet is easiest for you to tolerate. The nurse is providing education to Mr. Hayes on Diet following a colostomy. Which statement by the patient indicates the need for further teaching? I should limit my fluid intake to minimize output. The nurse is performing deep palpation during an abdominal assessment. How would the nurse explain the purpose of this procedure to Mr. Hayes? I am pressing deeply on your abdomen to feel your abdominal organs and detect masses. the nurse is completing an abdominal assessment and observes a pulsating midline mass. What would be the correct action by the nurse? Notify the provider immediately. THe nurse is performing deep palpation during an abdominal assessment. How would the nurse explain the purpose of this procedure to Mr. Hayes? I am pressing deeply on your abdomen to feel your abdominal organs and detect masses? While the nurse is performing blunt percussion at the costovertebral angle, the patient experiences a sharp pain. The nurse recognizes that this finding can be an indication of what condition? Kidney infection The nurse is palpating Mr. Hayes abdomen. Which technique would the nurse use to promote relaxation during the assessment? Ask Mr. Hayes to take slow, deep breaths through his mouth. The nurse is assessing a patients surgical incision. Which assessment finding would require an immediate call to the provider? Moderate amount of purulent drainage on the dressing. The nurse is preparing to perform an abdominal assessment on Mr. Hayes. Which instruction should the nurse give to the patient prior to performing the assessment? Lie flat on your back with your arms resting at your sides. The nurse is assessing a patient who underwent a colostomy yesterday. WHich assessment finding would require an immediate call to the surgeon? Dusky, purple stoma The nurse is providing discharge instructions to Mr. Hayes following surgery to place an ostomy. Under what circumstances should Mr. Hayes be instructed to call the provider? Change in color of skin around the stoma increased abdominal discomfort rash around the ostomy site stoma leaking more than usual The nurse is preparing to palpate the breasts of a female client. Which technique would be appropriate? Use the flat pads of three fingers A group of students is preparing for their clinical experience, for which they are required to demonstrate the techniques for examining the abdomen. The students demonstrate understanding of the proper sequence when they demonstrate the techniques in which order? Inspect, auscultate, percuss, palpate To promote relaxation of the abdominal muscles, which of the following would be most appropriate for the nurse to do? Place a pillow under both of the clients knees. When assessing the rectum, the nurse observes what appear to be engorged areas near the opening. The nurse would most likely document this finding as which of the following? Hemorrhoids A client calls the clinic and asks to speak to the nurse. The client tells the nurse that she has started taking morphine for advanced cancer, is constipated, and wonders what is causing it. What would the nurses best response be? People can become constipated when taking certain medications. What is considered a modifiable risk factor for breast cancer? Obesity While conducting the physical examination, which of the following assessments would require nurse to ausculate the abdomen? To identify bowel sounds A middle aged female tells the nurse that she is concerned because her breasts are not firm like they used to be and asks what might be causing this? What is an appropriate response by the nurse? Firmness of the breasts decreases with age as estrogen levels decrease While interviewing a client, a nurse asks the client whether she has ever noticed any lumps, swelling in the breasts. What other area associated with the possible risk for breast cancer should she ask about regarding the presence of lumps or swelling? Underarm A nurse is inspecting a clients nipple. Which of the following findings should the nurse recognize as a cause for concern? A recent retracted nipple that was previous everted. As part of an abdominal assessment, the nurse must palpate a client's liver. In which quadrant is this organ located? RUQ On inspection of a newborns breasts, the nurse notes that they are enlarges and elongated, with white liquid discharge. The infants mother is concerned about it. Which of the following should the nurse tell the mother regarding the finding? It is due to the influence of the maternal hormones and should resolve in a few days. A woman appears restless and is wringing her hands prior to having a clinical breast exam performed. Which statement by the nurse would be most appropriate? You seem to be anxious. Can you tell me what you are thinking? An adult male client reports hesitency when urinating. The nurse would further assess this for which complication? Prostate enlargement The client tells the nurse I am so glad i had a mastectomy and i will never have breast cancer again. How should the nurse best repsond? We need to continue to perform examinations. Breast cancer can reoccur. The client tells the nurse that she has benign breast disease and so she is not worried about lumps or nodules in her breasts. How would the nurse best respond? It is important to perform self examinations as there could be changes or additional lumps in your breasts that would need further examinations. The nurse is assessing an older adult client who has lost 2.27 kg since her last visit 1 year ago. The client tells the nurse that her husband died 2 months ago. The nurse should further assess the client for appetite changes The nurse is preparing to assess the abdomen of a hospitalized client 2 days after abdominal surgery. They nurse should first inspect the abdominal area A nurse is providing client education to a group of prepubescent girls at a local elementary school. What should you include in the presentation? Information about the stages of breast development The nurse is assessing a clients abdomen. Which technique is the nurse using two handed deep palpation A nurse is preparing to assess the cranial nerves of a client. The nurse is about to test CN 1. Which of the following would the nurse do? Ask the client to identify scents Loss of bone density that occurs with greatest frequency in postmenopausal women is called? Osteoporosis Moving a part of the body away from the midline is called? abduction Assessment of the musculoskeletal system usually proceeds from general to specific and from: head to toe The nurse walks into a clients room and finds the client is disoriented to time and place and is awake and responsive. What term best describes the client? Confused Lifestyle can play a big part in developing risk factors for stroke. Which of the following can reduce a clients risk for stroke? Maintaining a healthy weight regular exercise quitting smoking When evaluating a clients risk for cerebrovascular accident, which client would the nurse identify as being at highest risk 68 year old african american male with hypertension A client comes to the clinic and reports a sore knee. The nurse notes popping and cracking when the client attempts to bend the knee. The client exhibits signs of pain by facial expression. The nurse knows that the popping and cracking noises should be charted as? crepitus A nursery nurse is assessing neurologic status of a newborn, what area would the nurse be assessing? reflexes The nurse is assessing a 51 year old modbidly obese client who is seeking care for the recent changes of sensation in his feet and toes. The client is complaining of intermittent burning and tingling, in his feet that radiate up his legs. For what health problems should the nurse assess? Diabetic peripheral neuropathy Risk factors in which of the following are most readily cahnged to reduce the potential for falls? enviromental the nurse is assessing an older adult. which assessment finding would the nurse recognize finding associated with aging? kyphosis A client has sustained an injury to the cerebellum. which area should be the nurses primary assessment? coordination WHich technique should the nurse use to perform scoliosis screening in a school aged child? have the child bend forward at the waist. The nurse is preparing to perform the Romberg test on an adult male client. THe nurse should instruct the client to? Stand erect with arms at the sides and feet together. A neurologic change associated with normal aging is? a decrease in reaction time When preparing an education session for a group of women who have been identified as postmenopausal the nurse should include which teaching point? Increase intake of Vitamin D and Calcium What age do we start screening for scoliosis and how? 11-12 years old Standing behind the patient while the patient bends forward looking for any curves of the spine. How is bone pain described? Deep, dull, and boring. Muscle pain sore, tender, cramping pain with movement Palapation always compare side to side! Physical assessment strategies Assessment: Inspection Palaption ROM Muscle strength Lifespan considerations older adults - extra time for assessment gait speed assessment Fall risk morse fall scale hendrich fall risk model enviromental factors working conditions Muscle strenght Grading strength scale 0-5 5 being normal Always compare side to side Osteomyelitis open fracture, infection in bone Is a fracture the same as a broken bone? yes Neurological system Brain spinal cord and nerves Frontal lobe voluntary motor activity personality emotion intellect temporal lobe auditory cerebellum balance and coordination occipital lobe vision hypothalamus temperature and sleep regulation LOC level of conciousness PERRLA stands for pupils are equal, round, and reactive to light and accommodation Nerve pain burning, stabbing, electric shock like First sign of developing neurological problem change in LOC Romberg test feet together arm to the side, close eyes and observe for any swaying Babinski sign normal in babies up to 18 months Glasgow Coma Scale eye response verbal response motor response Highest score 15 out of 3 How many cranial nerves are there? 12 What sense does the olfactory nerve control? smell Which cranial nerve controls eye movement? Oculomotor Which cranial nerve controls hearing and equilibrium? vestibulocochlear/auditory Which cranial nerve is being assessed when the nurse asks the patient to raise eyebrows, purse lips, and smile? facial Which cranial nerve controls movement of the trapezius and sternocleidomastoid muscles? spinal accessory Which cranial nerve is being assessed when a patient is asked to swalow and the gag reflex is observed to be normal? glossopharyngeal what is an assessment of teh trigeminal nerve? Light touch over anterior scalp and jaw, clench teeth. What is the only cranial nerve that travels out of the cranium? vagus X What cranial nerve can cause syncope? Vagus X Vagus nerve affects digestion and heart rate Oculomotor III PERRLA What is the earliest and most sensitive indicator of altered cerebral function? Change in LOC When PERRLA is normal, which cranial nerve is responsible? Oculomotor CN III Abnormal Male breast enlargement gynecomastia lymphedema tissue swelling due to lymphatic obstruction Increase risk for breast cancer Menarche before 12 Menopause after 55 First pregnancy after 30 No pregnancies/no children Family history Inappropriate lactation galactorrhea RUQ liver, gallbladder LUQ stomach, spleen RLQ appendix LLQ terminal portion of colon What is one topic pertinent to ? food borne illness Bowel sounds hi pitched clicks and gurgles should hear one every 5-15 seconds or 5-30 minutes Mrs. Jones presents at the ED complaining of severe pain in her abdomen. She has a history of liver transplant. What would the nurse know NOT to do ? DO NOT!!!!! palpate the abdomen.