NURS 220 exam 1 UPDATED ACTUAL
Questions and CORRECT Answers
What are the major components of mental status assessment? - CORRECT ANSWER -Level of
Consciousness, Orientation, Affect/mood, Attention, Speech
What four things are you checking to see if the patient is oriented? - CORRECT ANSWER -person,
place, time, situation
What tools are used to assess depression and anxiety? - CORRECT ANSWER -Depression: PHQ-2,
If positive then PHQ-9
Anxiety GAD-2, If positive then GAD-7
What to ask about suicidality? - CORRECT ANSWER -Start with open-ended questions about
current feelings
What factors indicate an increased risk of suicide attempts? - CORRECT ANSWER -if they though
about harming themselves or others, if they feel like hurting themselves right now, and if they had a plan
How can you identify which drink has a stronger alcohol content? - CORRECT ANSWER -By
comparing the types of drinks and their alcohol by volume (ABV) percentages.
What is a Pack Year History in smoking? - CORRECT ANSWER -It is a calculation that reflects
the number of years a person has smoked multiplied by the number of packs smoked per day.
What should you ask if someone admits to using illicit drugs? - CORRECT ANSWER -Inquire
about the type of drugs used, frequency, and how much they took
What is the approach to interviewing patients who may be victims of domestic violence? - CORRECT
ANSWER -Change your approach to be sensitive, non-judgmental, and ensure privacy.
,What are flags or cues that may indicate possible abuse? - CORRECT ANSWER -Unexplained
injuries, changes in behavior, and inconsistent explanations.
Define Intimate Partner Violence. - CORRECT ANSWER -physical, sexual, or psychological harm
by a current or former partner or spouse
What are HITS and STaT used for? - CORRECT ANSWER -HITS: hurt, insult, threaten, scream
STaT: Have you ever been in a relationship where your partner has pushed or slapped you? Etc.
What is the RN's role regarding mandatory reporting of child abuse? - CORRECT ANSWER -
Report to MDHHS via CPS
must be made immediately by phone, followed by written report in 72 hrs
failure to report = legal consequences
What bruising patterns are considered expected versus unexpected in child abuse? - CORRECT
ANSWER -Expected bruising may occur in active children, while unexpected bruising includes
patterns or locations that are unusual for a child's activity level.
Define Elder Abuse. - CORRECT ANSWER -Elder abuse is any intentional or negligent act by a
caregiver or trusted individual that causes harm or serious risk of harm to a vulnerable elder.
What are physical cues of elder abuse? - CORRECT ANSWER -Signs may include unexplained
injuries, malnutrition, poor hygiene, and sudden changes in financial status.
What are ADLs? - CORRECT ANSWER -Activities of Daily Living, which include basic self-care
tasks such as bathing, dressing, and eating.
What is the difference between subjective and objective data in nursing? - CORRECT ANSWER -
Subjective data is what the patient reports, while objective data is what the nurse observes or measures.
, What does ABCs stand for in prioritization? - CORRECT ANSWER -Airway, Breathing,
Circulation.
Why is cultural competence important in nursing? - CORRECT ANSWER -It ensures that care is
respectful of and tailored to the cultural needs of patients.
What is the purpose of a complete health history? - CORRECT ANSWER -To collect
comprehensive and accurate data to inform patient care.
What is OLD CARTS in health history taking? - CORRECT ANSWER -A mnemonic for assessing
symptoms: Onset, Location, Duration, Characteristics, Aggravating factors, Relieving factors, Timing,
Severity.
What should be included in a comprehensive Past Medical History (PMHx)? - CORRECT
ANSWER -Previous illnesses, surgeries, hospitalizations, and any ongoing medical conditions.
What should you ask about allergies during a health history? - CORRECT ANSWER -Inquire about
the type of allergy, reaction experienced, and any previous treatments.
What is the purpose of a genogram in nursing? - CORRECT ANSWER -To visually represent
family relationships and health history, aiding in understanding genetic and hereditary conditions.
Capillary refill - CORRECT ANSWER -Time taken for the color to return after pressure.
Skin layers - CORRECT ANSWER -epidermis- Thin, top layer, avascular
dermis- connective tissue dense in collagen, nerves, blood vessels, and hair follicles
subcutaneous- adipose and loose for mobility
Questions and CORRECT Answers
What are the major components of mental status assessment? - CORRECT ANSWER -Level of
Consciousness, Orientation, Affect/mood, Attention, Speech
What four things are you checking to see if the patient is oriented? - CORRECT ANSWER -person,
place, time, situation
What tools are used to assess depression and anxiety? - CORRECT ANSWER -Depression: PHQ-2,
If positive then PHQ-9
Anxiety GAD-2, If positive then GAD-7
What to ask about suicidality? - CORRECT ANSWER -Start with open-ended questions about
current feelings
What factors indicate an increased risk of suicide attempts? - CORRECT ANSWER -if they though
about harming themselves or others, if they feel like hurting themselves right now, and if they had a plan
How can you identify which drink has a stronger alcohol content? - CORRECT ANSWER -By
comparing the types of drinks and their alcohol by volume (ABV) percentages.
What is a Pack Year History in smoking? - CORRECT ANSWER -It is a calculation that reflects
the number of years a person has smoked multiplied by the number of packs smoked per day.
What should you ask if someone admits to using illicit drugs? - CORRECT ANSWER -Inquire
about the type of drugs used, frequency, and how much they took
What is the approach to interviewing patients who may be victims of domestic violence? - CORRECT
ANSWER -Change your approach to be sensitive, non-judgmental, and ensure privacy.
,What are flags or cues that may indicate possible abuse? - CORRECT ANSWER -Unexplained
injuries, changes in behavior, and inconsistent explanations.
Define Intimate Partner Violence. - CORRECT ANSWER -physical, sexual, or psychological harm
by a current or former partner or spouse
What are HITS and STaT used for? - CORRECT ANSWER -HITS: hurt, insult, threaten, scream
STaT: Have you ever been in a relationship where your partner has pushed or slapped you? Etc.
What is the RN's role regarding mandatory reporting of child abuse? - CORRECT ANSWER -
Report to MDHHS via CPS
must be made immediately by phone, followed by written report in 72 hrs
failure to report = legal consequences
What bruising patterns are considered expected versus unexpected in child abuse? - CORRECT
ANSWER -Expected bruising may occur in active children, while unexpected bruising includes
patterns or locations that are unusual for a child's activity level.
Define Elder Abuse. - CORRECT ANSWER -Elder abuse is any intentional or negligent act by a
caregiver or trusted individual that causes harm or serious risk of harm to a vulnerable elder.
What are physical cues of elder abuse? - CORRECT ANSWER -Signs may include unexplained
injuries, malnutrition, poor hygiene, and sudden changes in financial status.
What are ADLs? - CORRECT ANSWER -Activities of Daily Living, which include basic self-care
tasks such as bathing, dressing, and eating.
What is the difference between subjective and objective data in nursing? - CORRECT ANSWER -
Subjective data is what the patient reports, while objective data is what the nurse observes or measures.
, What does ABCs stand for in prioritization? - CORRECT ANSWER -Airway, Breathing,
Circulation.
Why is cultural competence important in nursing? - CORRECT ANSWER -It ensures that care is
respectful of and tailored to the cultural needs of patients.
What is the purpose of a complete health history? - CORRECT ANSWER -To collect
comprehensive and accurate data to inform patient care.
What is OLD CARTS in health history taking? - CORRECT ANSWER -A mnemonic for assessing
symptoms: Onset, Location, Duration, Characteristics, Aggravating factors, Relieving factors, Timing,
Severity.
What should be included in a comprehensive Past Medical History (PMHx)? - CORRECT
ANSWER -Previous illnesses, surgeries, hospitalizations, and any ongoing medical conditions.
What should you ask about allergies during a health history? - CORRECT ANSWER -Inquire about
the type of allergy, reaction experienced, and any previous treatments.
What is the purpose of a genogram in nursing? - CORRECT ANSWER -To visually represent
family relationships and health history, aiding in understanding genetic and hereditary conditions.
Capillary refill - CORRECT ANSWER -Time taken for the color to return after pressure.
Skin layers - CORRECT ANSWER -epidermis- Thin, top layer, avascular
dermis- connective tissue dense in collagen, nerves, blood vessels, and hair follicles
subcutaneous- adipose and loose for mobility
