NUR 3066 FINAL REVIEW
QUESTIONS AND ANSWERS
(GRADED A+)
Components of the Mental Status Examination - ANSWER-A: Appearance
B: Behavior
C: Cognition
T: Thought Processes
Marijuana - ANSWER-reddened eyes, tachycardia, dry mouth, increased appetite,
loss of
coordination/balance
Cocaine - ANSWER-pupillary dilation, tachycardia or bradycardia, elevated or
lowered BP, sweating, chills,
nausea, vomiting, weight loss
Heroin - ANSWER-pinpoint pupils, decrease blood pressure, pulse, respirations and
temperature
Hallucinogens - ANSWER-tachycardia, nausea, increased blood pressure,
respirations or temperature, loss of
appetite, dry mouth, paranoia, psychosis
Inhalants: - ANSWER-slurred speech, lack of coordination, dizziness, delusions
Methamphetamines - ANSWER-pupillary dilation, tachycardia or bradycardia,
elevated or decreased blood
pressure, sweating or chills, nausea and vomiting, weight loss
Temperature - ANSWER-Normal -Oral 96.4-99.1 F -Rectal 97.1-100.1 F
Abnormal: Fever (hyperthermia): 100.4+F, Cold (hypothermia) <96.4 F
-Rectal temps are most accurate
-Tympanic temp utilized in peds often due to ease
Pulse Rate - ANSWER-Normal- 60-100 BPM
Abnormal: Bradycardia <60, Tachycardia >100
-Low pulse can be normal
-Pediatrics run higher and have a different scale of normal
-Doppler can be used if not palpable
Pulse Force - ANSWER-2+
0=absent, 1+=weak, thread, 3+=bounding
-Reflects strength of heart's stroke volume
Respirations - ANSWER-Normal- 10-20/minutes
, Abnormal: Bradypnea <10, Tachypnea>20
-Distract patient to get accurate result
-Pediatric population differs
-Con signal declining status
-Count for 30 seconds and x2 (count for full minute if suspected abnormality)
Oxygen Saturation - ANSWER-Normal: >95% on room air
Abnormal: <95% on room air
-Lung disease may cause lower normal reading
-Move pulse oximeter around if getting odd reading - could be due to placement
Blood Pressure - ANSWER-Systolic= maximum pressure during left ventricular
contraction, TOP reading
Diastolic= recoil/resting pressure between each contraction, BOTTOM reading
Pulse Pressure= difference between systolic and diastolic pressures and reflects
stroke volume
Causes of Abnormalities: medical diagnoses, medications, current state
Performing Blood Pressure Reading - ANSWER-Ensure cuff is correct size
Place around arm as directed (practice in lab)
Inflate to maximum level
Deflate cuff slowly and evently
Listen for Korotkoff sounds (Systolic= 1st sound heard, Diastolic= last sound before
silence)
Readings should always be even numbered
Do NOT do BP on mastectomy arm
Sources of Pain - ANSWER-Visceral: from internal organs
Somatic: from musculoskeletal tissues
Deep Somatic: from blood vessels, joints, tendons, muscles, bone
Cutaneous: from skin surface and subcutaneous tissues
Referred: from another body location (originated from another area)
Lesions
Assess CEPSLA - ANSWER-C: Color
E: Elevation
P: Pattern or Shape
S: Size
L: Location and distribution
A: Any exudate (color, odor)
Primary: - ANSWER-Macule and Patch: flat, nonpalpable, circumscribed border,
discolored
-Macule: less than 1 cm in size
-Patch: greater than 1 cm
-Example: freckles, measles, Mongolian spots, vitiligo
Papule and Plaque: elevated, solid, palpable, circumscribed border, any color
-Papule: less than 0.5 cm
-Plaque: greater than 0.5 cm
-Example: warts, psoriasis, actinic keratosis
QUESTIONS AND ANSWERS
(GRADED A+)
Components of the Mental Status Examination - ANSWER-A: Appearance
B: Behavior
C: Cognition
T: Thought Processes
Marijuana - ANSWER-reddened eyes, tachycardia, dry mouth, increased appetite,
loss of
coordination/balance
Cocaine - ANSWER-pupillary dilation, tachycardia or bradycardia, elevated or
lowered BP, sweating, chills,
nausea, vomiting, weight loss
Heroin - ANSWER-pinpoint pupils, decrease blood pressure, pulse, respirations and
temperature
Hallucinogens - ANSWER-tachycardia, nausea, increased blood pressure,
respirations or temperature, loss of
appetite, dry mouth, paranoia, psychosis
Inhalants: - ANSWER-slurred speech, lack of coordination, dizziness, delusions
Methamphetamines - ANSWER-pupillary dilation, tachycardia or bradycardia,
elevated or decreased blood
pressure, sweating or chills, nausea and vomiting, weight loss
Temperature - ANSWER-Normal -Oral 96.4-99.1 F -Rectal 97.1-100.1 F
Abnormal: Fever (hyperthermia): 100.4+F, Cold (hypothermia) <96.4 F
-Rectal temps are most accurate
-Tympanic temp utilized in peds often due to ease
Pulse Rate - ANSWER-Normal- 60-100 BPM
Abnormal: Bradycardia <60, Tachycardia >100
-Low pulse can be normal
-Pediatrics run higher and have a different scale of normal
-Doppler can be used if not palpable
Pulse Force - ANSWER-2+
0=absent, 1+=weak, thread, 3+=bounding
-Reflects strength of heart's stroke volume
Respirations - ANSWER-Normal- 10-20/minutes
, Abnormal: Bradypnea <10, Tachypnea>20
-Distract patient to get accurate result
-Pediatric population differs
-Con signal declining status
-Count for 30 seconds and x2 (count for full minute if suspected abnormality)
Oxygen Saturation - ANSWER-Normal: >95% on room air
Abnormal: <95% on room air
-Lung disease may cause lower normal reading
-Move pulse oximeter around if getting odd reading - could be due to placement
Blood Pressure - ANSWER-Systolic= maximum pressure during left ventricular
contraction, TOP reading
Diastolic= recoil/resting pressure between each contraction, BOTTOM reading
Pulse Pressure= difference between systolic and diastolic pressures and reflects
stroke volume
Causes of Abnormalities: medical diagnoses, medications, current state
Performing Blood Pressure Reading - ANSWER-Ensure cuff is correct size
Place around arm as directed (practice in lab)
Inflate to maximum level
Deflate cuff slowly and evently
Listen for Korotkoff sounds (Systolic= 1st sound heard, Diastolic= last sound before
silence)
Readings should always be even numbered
Do NOT do BP on mastectomy arm
Sources of Pain - ANSWER-Visceral: from internal organs
Somatic: from musculoskeletal tissues
Deep Somatic: from blood vessels, joints, tendons, muscles, bone
Cutaneous: from skin surface and subcutaneous tissues
Referred: from another body location (originated from another area)
Lesions
Assess CEPSLA - ANSWER-C: Color
E: Elevation
P: Pattern or Shape
S: Size
L: Location and distribution
A: Any exudate (color, odor)
Primary: - ANSWER-Macule and Patch: flat, nonpalpable, circumscribed border,
discolored
-Macule: less than 1 cm in size
-Patch: greater than 1 cm
-Example: freckles, measles, Mongolian spots, vitiligo
Papule and Plaque: elevated, solid, palpable, circumscribed border, any color
-Papule: less than 0.5 cm
-Plaque: greater than 0.5 cm
-Example: warts, psoriasis, actinic keratosis
