Final Exam: NURS190 / NURS 190 (Latest 2026 / 2027 Update) Physical Assessment | Questions & Answers | Grade A | 100% Correct – WCU

Final Exam: NURS190 / NURS 190 (Latest 2026 / 2027 Update) Physical Assessment | Questions & Answers | Grade A | 100% Correct – WCU Q: The different types of assessment techniques? Answer Inspection Palpation Percussion Auscultation Q: Which technique should the nurse use initially for each specific assessment? Answer Inspection Q: Assessment technique to illicit a diaphragmatic excursion? Answer Percussion Q: Technique used to listen to heart sounds? Answer Auscultation Q: Technique used to listen to crepitus who sustained a chest injury? Answer Palpation Q: What is the technique used to assess distended bladder? Answer Direct percussion Q: What is the technique used to assess sinus infection? Answer Direct Percussion Q: What is the technique used for percussion of the lungs? Answer Indirect Percussion Q: Identify the most common equipment used in the clinical area Answer Goniometer Doppler Wood lamp Skin fold caliper Transilluminator Stabio Stethoscope Ophthalmoscope Goniometer: measure the degree of joint extension and flexion Doppler: Asses non palpable pulses Wood lamp: presence of fungal infection of skin Skinfold Caliper: Measure thickness of subcutaneous tissue Transilluminator: Use to detect blood, solid or fluid or mass in body cavities Stabio meter: Height of pt. Stethoscope, penlight Ophthalmoscope: red reflex Q: Grading for pulses Answer 0 : absent 1+: weak thready 2+: normal 3+: brisk 4+: bounding Q: Location of pulses Answer Popliteal : behind the knees Femoral: inguinal area Q: What part of your hand do you use to assess skin temperature? Answer Dorsal part of hand Q: What part of your hand do you use to use percussion? Answer Tip of middle finger Q: Identify different types of lesions Answer Annular Target Dicerete Confluent Linear Grouped Annular: one circle Target: concentric circles (more than one circle of color) Discrete: separated Confluent: runs together Linear: form a line Grouped: Together Q: Wheal lesion Answer Lesion caused by insect bite or hive redden irregular border Q: Vesicle Answer Elevated lesion round or oval filled with clear fluid Smaller vesicle vs bulla Q: Bulla Lesion Answer Larger vesicle More than 0.5 cm Q: How do you grade edema Answer 0: no edema 1+: 2mm 2+: 4mm 3+: 6mm 4+: 8mm Q: Cranial Nerves Answer Answer I: olfactory : 2 senses II: optic : Snellen Chart III: oculomotor : PERRLA and Cardinal field of gaze IV: trochlear: PERRLA and Cardinal field of gaze V: trigeminal : TMJ VI: abducens :PERRLA and Cardinal field of gaze VII: facial : Smile, frown, puff cheeks, raise eyebrows VIII: vestibulocochlear : Whisper test and Rombergs test IX: glossopharyngeal: Hold trachea, swallow, tongue depressor X: vagus: Swallow and repeat phrase XI: accessory : Move shoulders up and down with and without resistance XII: hypoglossal: Stick tongue out, side to side, up and down 10 Lymph nodes 1. Periauricular: in front of ear 2. Postauricular: back of ear 3. Occipital: behind head 4. Sub mental: under front chin 5. Submandibular: under side of jaw 6. Retropharyngeal or tonsillar: under upper part of jaw 7: Superficial cervical chain: front of sternocleidmastoid 8. Deep cervical chain: deep in the sternocleidomastoid muscle 9. Posterior cervical chain: behind sternocleidomastoid 10. Supraclavicular: above clavicle Lymph nodes in adults versus children Adults are non palpable if palpable there is a sign of infection Children are palpable but still need to see provider Vascular lesions: Venous lake Soft lesion on lips or neck Elevated Dark blue Compressible Vascular lesions: port wine stain Flat Irregular shaped Pale red to deep purple red Color deepens in response to exertion, emotion or when patient cries, elevated temperature Hemangioma Bright red raised lesions non blanched with pressure Present at birth or a few months and goes away at age of 10 Spiderangioma Bright red with tiny radiating blood vessels Ranging from pinpoint to 2cm Blanches with pressure Abdominal palpation Light : use finger pads, 1/2 - 1 cm, safest Moderate: use finger pads, 1-2 cm, determine depth size shape and consistency and mobility of orders, tenderness, and pulsations Deep: use palm of hand up to metacarpal joint, 2-4cm, caution, use to assess organs deep within the body (liver, kidney) Assess head of patient and you notice sores that have been there for months, what you suspect? Skin malignancy or skin cancer Lyme Disease what would you ask patient? Have you been hiking or camping lately? Due to the bite of the tick What do you do when your patient refuses to continue with the physical examination? Document what was done and what was refused Nystagmus jerky movement of eyes during the 6 cardinal field of gaze Weber Test Activate the thinne of the tuning fork and put it on the midline of skull Negative: pt hear vibration equal lateralization on the right and left Positive: lateralization goes to defected ear Rhinne Test Activate thinne of tuning fork and place it at the mastoid then midline of skull Normal: AC 2x greater than BC Transillumination Red glow: sinuses are normal Absent of red glow: sinuses are filled with fluid Red reflex illicit with opthalmoscope distance to eyelash Presbyopia Elderly patient has difficulty with near vision (farsightedness) Hyperopia Adult difficulty with near vision (farsightedness) Myopia Adult difficulty with far vision (nearsightedness) In an optometry which patient would require immediate attention glaucoma: increase pressure in eyes can lead to blindness it is decreased peripheral vision Ear Infections Otitis externa: drainage but tympanic membrane pearly grey and is not infected Otitis media: tympanic membrane and ossicles Otitis interna(laryngitis): Cochlea and vestibule, manifestations of vertigo, n/v, and balance (+Rombergs test) Otoscope is used for tunneling light in the ear canal What is the manifestations of patient retinal detachment of right eye? diminished vision of right eye What technique will the nurse use to assess extraoccular movement of the eyes 6 cardinal field of gaze: H or wheel wagon method Leading cause of blindness in the US? diabetic retinopathy Craniosynostosis Infant has: Elongated head, and face Orbit of eyes are altered Hydrocephalus Infant: Enlarged head See veins on skull of baby due to CSF White patches on the tympanic membrane indicate? Previous scarring from ear infection How to test for Rombergs test? For 20 seconds have pt stand straight up with arms to side feet together and eye closed Abnormal: any swaying more than 2 in NI: get BSC Normal: no swaying Snellen test of 20/30 reading Patient with normal vision can see the chart at 30 ft while you can see it at 20 ft Types of headache Migraine Cluster Sinus Tension Migraine: See spots, flashes of light Pulsating pain, nauseated depressed, restless, irritable Cluster: Sudden, numerous episodes one side, behind eye Numerous episodes Sinus: due to sinus infection Tension: Gradual, unilateral or bilateral Muscle contraction Stress, overwork, position Entropian versus Extropian Entropian: upper lid is inverted, irritating the cornea Extropian: lower lid is exposed, conjunctiva is exposed What is the most common type of hyperthyroidism? Graves disease When do you advise the patient to perform a self breast exam (SBE)? The same day every month if the pt is still menstruating advise the patient to examine it 3 to 5 days after when the hormones are more stable What is the common cause of begin nipple discharge or post menopausal patient? Intraductal papilloma A serous or serosangiuneous Patient with an orange peel or Peau D' Orange is a sign of malignancy any change to the breast lump must be further evaluated by the patient What is the most reliable indicator for central cyanosis when assessing an asthmatic pt? Oral mucosa When you are listening to the lungs using whispered pectoriloquy and the pt has bilateral PNA and both lungs are filled with fluid.. What sounds would you hear? Loud, clear bilaterally When you are listening to healthy lungs using the whispered pectoriloguy what do you hear? Soft and indistinguishable Alveoli The functional unit of the lung. What is the most appropriate technique in assessing the respiratory system is? Assessing from side to side because you are comparing the right and left lungs for any abnormally 4 normal breath sounds Tracheal Bronchial Bronchovesicular Vesicular tracheal: over trachea, IE , harsh high pitched bronchial: superior to each clavicle and 1st intercoastal space, EI , loud high pitched bronchovesicular: over major bronchi 2nd and 3rdICS, between scapula, I=E , medium loudness medium pitch vesicular: remainder of lungs, IE , soft low pitched Abnormal respiratory pattern Tachypnea Hyperventilation Bradypnea Hypoventilation Cheyne-Stokes Biot's (Ataxic) Tachypnea: 24 Rapid, Shallow Hyperventlation: 24, Rapid, deep Bradypnea: 10 Slow Regular Hypoventilation: 10 Irregular, low/shallow Cheyne-Stokes: Deep, apnea, regular when pt dying Biot's (Ataxic): Shallow, deep, apnea, irregular, when pt. has brain tumor or injury Eupnea normal breathing, even regular I=E Eupnea with a sigh: normal Eupnea with multiple signs: abnormal leading to hyperventilation Obstructive breathing prolonged expiration common in COPD, chronic bronchitis, or asthmatic pt. Differentiate between adventitious breath sounds Fine/Coarse/Crackles Fine: High pitched, short crackling Collapsed or fluid filled alveoli open Coarse: Loud, moist, low pitched, bubbling Collapsed or fluid filled alveoli open Crackles: pt has lobar pna due to collapsed and fluid filled lungs Differentiate between adventitious rhonchi lung sounds Wheezes/Rhonchi/Stridor/Friction Rub Wheezes (Sibilant): Expiration/Inspiration when severe High pitched continuous Blocked airflow as in asthma, infection, foreign body obstruction Rhonchi (Sonorous): Expiration/Inspiration change with cough Low pitched continuous, snoring, rattling Fluid-blocked airways Stridor Insipration Loud high pitched crowing heard w/o stethoscope Obstructed upper airway Friction Rub Inhalation/Exhalation Low pitched grating, rubbing pleural inflammation Normal configuration of the chest elliptical lateral diameter larger than anteroposterior diameter 2:1 Chest configuration for children Prior to age of 6 will have barrel chest At age 6 they will have elliptical Barrel Chest Anteroposterior diameter = lateral diameter COPD, Children before 6 years old Pectus Carinatum Pigeon Chest Congenital deformity Forward placement of sternum with depression of the adjacent costal cartilage no treatment Pectus excavatum Funnel Chest Congenital deformity Depression of sternum and adjacent costal cartilage mainly xiphoid process cause heart murmurs and lung problems surgical intervention to alleviate depression of sternum Scoliosis Lateral curvature of thoracic and lumbar spine Kyphosis exaggerated thoracic curvature common in elderly and osteoporosis Lordosis exaggerated lumbar curve common in women in the 3rd trimester Normal sound in lungs on percussion in between ribs resonance Hyper-resonance air trapped in lungs Left pleural effusion what lung sounds will you hear? Absent breath sounds What is the part of the chest where you perform cardiac assessment percordium Where is the correct location of PMI? PMI: Point maximal impluse 5 ICS left mid clavicular line What is the landmark for ERBs point 3rd ICS LSB What is the landmark for Angle of Louis Articulation of manubrium and body of sternum in line with 2nd rib Arterial insufficiency vs. venous insufficiency Arterial insufficiency: Legs are cold No hair growth From fatty plaque or calcification Venous insufficiency: Skin temp is warm,dry incompetent valves or blood clots ECG Electrical paper recording deflections Depolarization contraction after stimulus of electrical current where cardiac cells are more positively charged Repolarization relaxation after contraction where the inside of cardiac cells return to negative charge P Wave atrial depolarization (contraction) 0.8 secs PR interval time needed for the electrical current to travel across to atria and arrive at AV node .12 to .20 secs Atrial Reploarization Occurs behind QRS QRS complex ventricular depolarization (contraction) .08 to .11 secs T wave ventricular repolarization (relaxation) QT interval beginning of ventricular depolarization through ventricular repolarization Test to perform to determine the patency of radial and ulnar arteries Allen's Test Raynaud's disease rubor (redness), cyanosis, paleness spams, tingling sensation common in young healthy female secondary to connective tissue disease, drug intoxification, trauma, pulmonary htn How to assess for DVT Deep vein thrombosis sudden swelling of one leg with dependence edema NI: refer to Dr. asap due to it becoming a VTE that can migrate to lungs and result in PE Pathologic cardiac murmur associated to structural abnormalities of heart such as mitral regurtation, tricuspid stenosis, mitral stenosis What is the location of the landmark of aortic area 2nd ICS RSB S2 2nd heartbeat DUB Closure of semilunar valves Heard loudest at base of heart S1 1st heartbeat LUB Closure of AV valves mitral and tricuspid Heard loudest at apex of heart Apex and base of heart is located at Apex and base of lung is located at Heart Apex bottom, base top Lung Apex top, base bottom S3 ventricular gallop follows S2 LUB DUB TAH S4 atrial gallop follows S1 TAH LUB DUB SA node Pacemaker of heart 60-100 joules/min AV node fires 60-80 joules/min Bundle of His 40-60 joules/min What are the major risk factors of heart disease 1. Hypertension 2. Obesity 3. High Cholesterol 4. Diabetes. 5. Smoking Foramen Ovale Hole between right and left atria Closes shortly after birth Ductucs Arteriosus Hole between pulmonary artery and descending aorta Closes 24-48 hours after birth Nerves fibers that supplies the heart sympathetic vs parasympathetic sympathetic: stimulates the heart, increase HR and dilatation parasympathetic: doesn't stimulate the heart, reduces HR, constrict coronary arteries Normal BP below 120/80 Prehypertension 120/80 - 139/89 Hypertension 140/90 and above Patient with new arterial venous graft, what technique to perform to determine patency of graft? palpate the site for a thrill Abdominal mapping 4 quardrants 9 regions Landmark for assessing CVA Tenderness CVA blunt percussion Intake Output pt retaining fluid Postive Blumbergs sign sharp stabbing pain as the compressed abdomen returns to non compressed abdomen state due to periotinnitus, peritineal irriation EMERGENCY Positive Rosvings sign Sharp pain RLQ when the nurse compress LLQ Appendicitis or perioteneal irritation Positive Psosas sign RLQ pain when right leg raised up with resistance Appendicitis Positive Murphy's sign RUQ pain when pt deep breathes and nurse is palpating LLQ Cholecystitis Positive Cullen's sign Ecchomoysis or bluish discoloration or hematoma on periumbical area or entire abdomen ruptuer etopic pregnancy or bleeding in abdomen McBurney's point Right inguinal area middle third Acute Appendicitis Percuss abdoment the four quadrants what do you hear Tympanic sound Percuss over organ dullness Different contours of abdomen Skinny: flat Very Skinny: Scaphoid Fat: Round (children) Protuborent: 3rd trimester of pregnancy, ascites, obese Sequence of Auscultating abdomen RLQ RUQ LUQ LLQ During inspection of the abdomen what do you do? Look at all sides on eye level Use penlight to shine light over abdomen to see if there is shadow If there is a shadow that means a mass or tumor What does strong abdominal pulsation determine? Call doctor because it can indicate triple A. Aortic Abdominal Aneryusm When assessing the LUQ what are the main organs stomach and spleen When assessing the RUQ what are the main organs Liver and gallbladder Diverticulitis pain in LLQ Appendix inflammation RLQ Differentiate between the Hepatitis Hepatitis A: fecal to oral, most common in children due to not washing Hepatitis B: parentally, sexually, perinatally Hepatitis C: Blood, parentally common with people with tattoos Hepatitis D: parentally, sexually, perinatally Hepatitis E: fecal oral route, common with those who travel to India, Africa, Asia and Central America due to dirty water supply Dsyuria difficult or painful urination Oliguria output below 400 cc in 24 hrs Anuria output below 100 cc in 24 hrs Polyuria frequent urination hematuria blood in the urine uremia presence of urinary waste in the blood s/s: n/v, anorexia, altered mentation, uremic frost, edema, fatigue, weight loss nocturia excessive urination at night Glycouria sugar in urine Normal bowel sounds on ausculation of abdomen 5-30x/ minute irregular high pitched gurgling Borborygmi frequent loud gurgling sound normal when person has not eaten 5-7 hrs abnormal when there is bleeding in stool Classification of bowel sounds Hyperactive Hypoactive Absent Friction Rub Hyperactive: over 30x/min due to diarrhea or gastritis Hypoactive: below 5x/min due to constipation or bowel obstruction Absent: due to perillitic ileus or complete bowel obstruction Friction rub: grating rubbing due to inflammed organs in abdominal Colitis vs. Crohn's Chrons: chronic inflammation of intestines and involves any part. S/S: abdominal pain, diarrheaNo medical or surgical intervention Colitis: inflammation of colon S/s: abd. pain, diarrhea, blood in stool Require long term medical intervention Glomeruli cluster of capillaries of kidneyfilters one liter or fluid/minute to remove toxins waste from the blood Hallmark of chronic renal failure uremia Which clinical mainfestation does the nurse anticipate when assessing tremors related to Parkinsons disease Rhytmic shaking What concept should the nurse use to explain why there is a decrease in height as we age Shortening of vertebral column Osteoarthritis inflammation of the bone and joint pain aggrevated by activity rheumatoid arthritis a chronic autoimmune disorder in which the joints and some organs of other body systems are attacked pain imporved while patient is doing activity What symptoms should the nurse detect when the pt is developing OM with open metacarpal fx OM: osteomyletisis bone infection Signs of fever abduction vs adduction Abduction - away from midline Adduction - towards midline Pt more prone to osteoporosis Weaking of the bones is osteoporosis people that have sedentary lifestyle/no exercise What are the findings with pt with carpal tunnel syndrome when conducting phanels test tingling sensation and numbness over median nerve, palmar surface of thumb, index, ring, middle finger, shoulder, neck and chest conduct for 60 secs Tinel's test direct percussion of the location of the median nerve at the wrist produces no symptoms in the normal hand Pt has shoulder pain what findings will indicate rotator cuff injury pt will be unable to abduct the arm of shoulder Brachioradialis reflexes Pt elbow in line with waist Arms on side palm in semi prone position Hit DTR hammer (flat end) 2-3 inches above the wrist Normal findings 2+ bicep reflex illicited by indirectly with the pointy end of DTR hammer at the AC area normal findings 2+ 2 types of nervous system central nervous system and peripheral nervous system What findings will the nurse document when the patient is having difficulty with ambulation with Unsteady gait, wide base, slapping and swaying Ataxia Graphisthesia Assess by draw on palm on pt and ask the pt to identify what you drew pt eyes closed cortical disease inability to identify what was written with graphisthesia involves pathology of cerebral cortex or basal ganaglia parkinsions, neuropathy Steroegnosis place a key or familiar object in the patient's hand and ask the patient to identify it pt eyes closed Assessing sensory function? touch pt with sharp or dull object with eyes closed What would the nurse expect for assessing a normal Achilles tendon reflex plantar flexion heel jump When caring for a client with T4 injury, what is the indication that the client is at risk for experiencing autonomic disreflexion client bladder distended When assessing for pt with Bell's palsy Atrophy of one side of face Pt will have pain behind ears, tinnitus with headache, imparied tase, difficulty with speech and eating, muscle distortion Babinski reflex Reflex in which a newborn fans out the toes when the sole of the foot is touched plantar reflex Position the thigh in a slight external rotation. With the reflex hammer, draw a light stroke up the lateral side of the sole of the food AND inward across the ball of the foot like in an upside down J shape. Normal Response: Plantar flexion of the toes (toes curl) and inversion and flexion of the forefoot. Autonomic Dysreflexia common in ppl wwith spinal injuries T6 or higher, -severe hypertension a nurse is reinforcing teaching with a client about manifestations of lithium toxicity. which of the following manifestations should the nurse include in the teaching vomiting and diarrhea a nurse is reinforcing teaching with a client who has a new prescription for monoamine oxidase inhibitor (MAOI).which of the following foods should the nurse instruct the client to avoid while take an MAOI aged cheese A client has a lithium level of 1.2 mEq/L. Which of the following interventions by the nurse is indicated? no intervention is necessary at this time a mother is concerned about her child being given stimulant medication for ADHD. the nurse tells the mother, which of the following medications was the first nonstimulant medication specifically designed and tested for ADHD atomoxetine the nurse has completed health teaching about dietary restrictions for a client taking monoamine oxidase inhibitor. the nurse will know that teaching has been effective by which of the following client statements it will be difficult for me to avoid pepperoni the nurse is teaching the client with anxiety about the mechanisms of benzodiazepines. which of the following is increased with this medication GABA when the client experiences facial flushing, a throbbing headache, nausea and vomiting after consuming alcohol while taking disulfiram the nurse is aware that this is due to which of the following the intended therapeutic result which of the following antidepressant drugs is a preferred drug for clients at high risk of suicide sertraline the nurse is educating a client and family about strategies to minimize the side effects of antipsychotic drugs. which of the following should be included in the plan? select all apply developing an exercise program is important increase foods high in fiber use sunscreen when outdoors which of the following side effects of lithium are frequent causes of noncompliance? select all that apply lethargy weight gain a client asks how his prescribed alprazolam helps his anxiety disorder. the nurse explains during teaching of medications that antianxiety medications such as alprazolam affect the function of which neurotransmitter that is believed to be dysfunctional in anxiety disorders GABA An anxiolytic agent, lorazepam, has been prescribed for the client. Which of the following statements by the client would indicate to the nurse that client education about this medication has been effective? this medication will relax me so i can focus on problem solving a client is being discharged on disulfiram which instruction for antabuse should the client receive read products labels carefully to avoid all products containing alcohol A nurse is exploring treatment options with a client addicted to heroin. Which information regarding the use of methadone is important for the nurse to include? methadone will meet the physical need for opiates without producing cravings for more a client with bipolar disorder has been taking lithium and today his serum blood level is 2.0mEq/L what effects would the nurse expect to see nausea, diarrhea, and confusion a client with depression has been taking an SSRI fluoxetine for the last 3 months and has noticed improvement of symptoms. the nurse inquires about any side effects. which of the following would the nurse expect the client to report a decrease in sexual pleasure during intimacy one week after beginning therapy with thiothixene the client demonstrates muscle rigidity a temperature of 103 F an elevated serum creatinine phosphokinase level stupor and incontinence the nurse should notify the physician because these symptoms are indicative of neuroleptic malignant syndrome which of the following increases the risk for neuroleptic malignant syndrome dehydration the nurse is teaching on the effects of antipsychotic medications to the client and family. which of the following disorders are extrapyramidal symptoms that may be caused by antipsychotic drugs select all apply dystonia akathisia pseudoparkinsonism Several medications are prescribed for a client who has anorexia. Which medication may be prescribed to help treat the client's distorted body image? olanzapine a child with ADHD reports to his parents that he does not like the side effects of his medicine adderall the parents ask the nurse for suggestions to reduce the medications negative side effects the nurse can best help the parents by offering which advice have the child eat good breakfast and snacks late in the day and at bedtime A child with attention deficit hyperactivity disorder is taking methylphenidate (Ritalin) in divided doses. If the child takes the first dose at 8 AM, which behavior might the school nurse expect to see at noon? increased impulsivity or hyperactive behavior a nurse is caring for a client who receives lamotrigine daily for bipolar disorder and reports a rash on his arm which of the following actions should the nurse take withhold the next dose of the medication a nurse is teaching a family member and client who has a new diagnosis of Alzheimer's disease and is to start taking donepezil. which of the following statements should the nurse include in the teaching take this medication in the evening at bedtime the nurse is planning disrcharge teaching for a client taking clozapine (clozaril) which of the following is essential to include remind the client to go to the lab to have blood drawn for a white blood cell count characterized by a pervasive pattern of social and interpersonal deficits marked by acute discomfort with and reduced capacity for close relationships as well by cognitive or perceptual distortions and behavioral eccentricities schizotypical personality disorder characterized by a pervasive pattern of detachment from social relationships and restricted range of emotional expression in interpersonal settings schizoid personality disorder characterized by pervasive mistrust and suspiciousness of others paranoid personality disorder characterized by pervasive pattern of excessive emotionality and attention seeking histrionic personality disorder pervasive and enduring pattern of unstable interpersonal relationships, self image and affect marked impulsivity frequent self mutilation behavior (mrs. nobles favorite ) borderline personality disorder characterized by a pervasive pattern of grandiosity need for admiration and lack of empathy narcissistic personality disorder characterized by a pervasive pattern of disregard for and violation of the rights of others and with the central characteristics of deceit and manipulation antisocial personality disorder characterized by a pervasive and excessive need to be taken care of, which leads to submissive and clinging behavior and fear of separation dependent personality disorder characterized by a pervasive pattern of preoccupation with perfectionism, mental and interpersonal control, and orderliness at the expense of flexibility , openness and efficiency obsessive compulsive personality disorder characterized by pervasive pattern of social discomfort and reticence, low self esteem, and hypersensitivity to negative evaluation avoidant personality disorder disorder has two subtypes, in one most commonly called water depression or fall onset people expericnce increased sleep, appetite and carbohydrate cravings, weight gain, interpersona conflict irritability and heaviness in the extremities beginning in late autumn and abating in spring and summer. seasonal affective disorder a chronic persisitent mood disturbance characterized by symptoms such as insomnia, loss of appetite, decreased energy, low self esteem, difficulty concentrating and feelings of sadness and hopelessness that are milder than those of depression persistent depressive disorder a a persisient angry or irrtable mood, puncturated by servere , reccent emper outbursts disruptive mood dysregulation disorder a severe and debilitating psychiatric illness with acute onset in the days following childbirth symptoms begin with fatigue sadness emotional lability poor memory and confusion and progress to delusions hallucinations poor insight and judgement and loss of contact with reality this medical emergency requires immediate treatment postpartum psychosis is defined as recurrent moderate psychological and physical symptoms that occur during the week before menses and resolving with menstruation approximately 20% to 30% of premenopausal women are affected by affective and or premenstrual dysphoric disorder typically involves 2 weeks or more of a sad mood or lack of interest in life activites with at least four other symptoms of depression such as anhedonia and changes in weight sleep, energy, concentration, decision making, self esteem and goals twice as common in women and has a one and a half to three times greater incidence in first degree relatives than in the general population major depressive disorder is the most common complication of pregnancy in developed countries the symptoms are consistent with those of depression with onset within 4 weeks of delivery postpartum depression characterized by mild mood swings between hypomania and depression without loss of social or occupational functioning cyclothymic disorder disorder in which the client has one or more manic or mixed episodes usually accompanied by major depressive episodes bipolar I disorder a period of abnormally and persistently elevated expansive or irritable mood lasting 4 days does not impair the ability to function and does not involve psychotic features hypomania disorder in which the client has one or more major depressive episodes accompained by at least one hypomanic episode bipolar II disorder a distinct period during which mood is abnormally and persistently elevated expansive or irritable mania a client asks the nurse why he has to go to therapy and cannot just take his prescribed antidepressant medication which would be the most therapeutic nursing intervention stating medication help your brain function better but the therapy helps you achieve lasting behavior change a client is admitted for major depression. the client has stated that nothing seems to bring im pleasure anymore. what should the nurse expect to find during assessment anhedonia, feelings of worthlessness, and difficulty focusing a client who is depressed states i think my family would be better off without me they don't need to worry which would be the most appropriate response by the nurse are you planning to commit suicide a client who is manic threatens others on the unit. which would be the initial nursing action in response to this behavior setting limits on aggressive and intimidating behavior the client with mania attempts to hit the nurse which is the best response by the nurse do not swing at me again if you cannot control yourself we will help you which would the nurse provide to best meet the nutritional needs of a client who is manic ham sandwich, cheese slices, milk the client presents to the emergency department with a flat affect. the family is concerned about the lack of family involvement with the client. which variables represent the highest risk for developing major depressive disorder divorced substance abuse mood disorder in first degree relatives a client calls the emergency department of the local hospital reporting that after 16 yeaers of heavy drinking he is tired and wants to quit cold turkey what would be the best response by the nurse it is not safe to stop drinking suddenly without medicine a client has been admitted to the inpatient unit after using inhalants recently upon assessment the nurse finds the client with slurred speech and nystagmus which of the following is an antidote to treat inhalant toxicity there is no antidote a client is being discharged from treatment for addiction to cocaine. which statement made by the client would cause the most concern for the nurse i can still hangout with my old friends i am just not going to use an intoxicated client was admitted for trauma treatment last night at 2:00 am when should the nurse expect to be alert for withdrawal symptoms between 8 and 10 am today 6 to 8 hours after drinking stopped the nurse is working in an intensive care unit and observes that some clients do not respond to injections to diazepam (valium) when the injections are given by a particular nurse the nurse returns from lunch exhibiting slurred speech and euphoria which is the best action for the nurse to take call the manager and report the observations a client with borderline personality disorder says to the nurse i feel so comfortable talking with you you seem to have a special way about you that really helps me which would be the most appropriate response by the nurse i'm here to help you just as all the staff members are a client with dependent personality disorder has a goal to increase her problem solving skills which client behavior would indicate progress toward meeting that goal asking questions a nurse is teaching a client with borderline personality disorder to reshape thinking patterns which is an example of a cognitive restructuring technique that would be helpful for this client recognize negative thoughts and replace them with positive ones the client is talking to staff members individually and attempting to manipulate them which of the following are important in the limit setting technique to deal with manipulative behavior select all that apply identifying the consequences if the limit is exceeded stating the behavioral limit identifying the expected or desired behavior the client often used attention seeking behaviors which of the following nursing interventions are most important in a plan of care for a client with histrionic personality disorder select all that apply provide factual feedback about behavior teach social skills a nurse is assessing with a diagnosis of huntington's disease in the later stages the client has severe cognitive defects in this case the nurse will also likely find which classic symptom choreiform movements the caregiver of a client with Alzheimer's disease reports to the nurse that often the client will suddenly become angry during meals and nothing seems to calm him down the nurse teaches the caregiver to use distraction techniques which response would be best to teach as an example of this technique lets look at what is on television the nurse caring for an elderly woman with dementia has asked the woman's children to bring old photo albums when they visit the nurse observes the actions of the client as she talks about the photos which best describes the usefulness of viewing photos when caring for dementia client viewing photos is a form of reminiscence therapy for the client which statement by the nurse would be most appropriate to the family member who is the primary caregiver to a client with dementia yes it is important for you to spend some time relaxing and doing what you like to do this will help you to be better prepared to manage the demands of the caregiver role the nurse is performing a health history and assessment of client exhibiting signs of delirium the nurse asks the client and family members about possible causes of the delirious state which would the nurse likely attribute as underlying causes for the clients delirium select all that apply dehydration recent alcohol use use of antihistamines sleep disturbances exposure to paint or gasoline which are possible sources of frustrations for nurses caring for person with dementia the clients do not retain explanantions or instructions so the nurse must repeat the same things continually it can be difficult to remain positive and supportive to clients and family because the outcome is so bleak the nurse may get little or no positive response or feedback from clients with dementia the clients may seem not to hear or respond to anything the nurse does a client has been referred to a mental health center by a juvenile court after being arrested for vandalism at the mental health center the client refuses to participate in scheduled activates the client seen pushing another client causing the person to fall which approach by nursing staff would be most therapeutic establishing firm limits the nurse has been working with the family of a small child with oppositional defiant disorder the nurse is feeling very frustrated because the parents refuse to implement effective parenting skills that the nurse has taught what is the best nursing action at this time try to remember that the parents are trying to the best of their ability to carry out the suggestions which is the most important reason for the nurse who care for children with conduct disorders to discuss feelings, fears, or frustrations with colleagues to keep negative emotions from interfering with the ability to provide care to clients with problems with aggression which are important points for the nurse to consider when working with clients with disruptive behavior disorders and their families? select all that apply remember to focus on the clients strengths and assets as well as their problems focus on positive actions to improve situation and/or behaviors avoid a blaming attitude toward clients and/or families which steps are involved in limit setting? select all that apply inform clients or the rule or limit state expected behavior explain the consequences if clients exceed the limit a client diagnosed with anorexia nervosa is newly admitted to an inpatient psychiatric unit which nursing intervention takes priority assessment and monitoring of vital signs and lab values to recognize and anticipate medical problems a client is being admitted to the inpatient psychiatric unit with a diagnosis of bulimia nervosa the nurse would expect this client to fall within which age range 18 to 22 years old a nurse sitting with a client diagnosed with anorexia nervosa notices that the client has eaten 80 percent of lunch the client asks the nurse what do you like better hamburgers or spaghetti which is the best response by the nurse lets focus on your continue improvement you ate 80 percent of your lunch several medications are prescribed for a client who has anorexia which medication may be prescribed to help treat the clients distorted body image olanzapine which of the following interventions would be appropriate for a client with anorexia nervosa having the client view of staff for 90 minutes after each meal which of the following would be most supportive for family and friends of a client with an eating disorder emotional support, love and attention a nurse is discussing a client's condition with the client family member states that the client has a long history of mental retardation the nurse corrects the family member by explaining that which is the correct term for this condition intellectual disability a parent of a child with autism spectrum disorder asks the nurse if there is anything that can be done to control the Childs tantrums which options should the nurse inform the parents that may be appropriate explore the use of antipsychotic medications to control tantrums a young client has been brought to a clinic for evaluation the client has developed several motor tics and shouts throughout the day the mother states this has been going on for over a year which disorder does the nurse suspect this to be tourette disorder the parents of an autistic child ask the nurse will my child ever be normal which would be the most appropriate response by the nurse your child will probably always have some autistic traits which statement would indicate that medication teaching for the parents of a 6 year old child with attention deficit hyperactivity disorder has been affective wel be sure to record his weight on a weekly basis a client diagnosed with hypochondriasis reports to the nurse that other doubt the seriousness of the clients illness the client is angry frustrated and anxious which nursing intervention takes priority acknowledge the clients frustrations without fostering continued focus on physical illness a client reports severe pain during intercourse since being sexuallly assaulted three years ago which is the first step in confirming the diagnosis of a pain disorder ruling out a physical cause of pain a client with recurrent headaches has been told by the physician that the cause is likely psychosomatic the client reports this conversation to the nurse and sys that just cant be true my head hurts so bad sometimes that it makes me sick to my stomach which is the nurses best response the pain in your head is very real the husband of a woman with a somatic symptom illness ask the nurse why the doctors cannot find anything wrong with her which would be the appropriate explanation for then nurse to offer there is no physical cause mental distress is causing the symptoms even thought she is not aware of it which of the following accurately describes how somatic symptoms are distinguished from factitious disorder and malingering in malingering or factitious disorders people willfully control the symptoms and in somatic symptoms illnesses clients do not voluntarily control their physicals symptoms a client asks the nurse why do i have to go to counseling why can i just take medication the response best by the nurse would be medication combined with therapy help you change how well you function Pale or flushed face, yelling, swearing, agitation, threatening, demanding, clenched fists, threatening gestures, hostility, loss of ability to solve the problem or think clearly escalation restlessness, anxiety, irritability, pacing, muscle tension, rapid breathing, perspiration, loud voice and anger triggering remorse, apologies, crying, quiet, withdrawn behavior postcrisis Lowering of voice; decreased muscle tension; clearer, more rational communication; physical relaxation recovery loss of emotion and physical control, throwing , kicking, hitting, spitting, biting, scratching, shrieking, screaming, inability to communicate clearly crisis right to self determination, independnce autonomy obligation to honor commitments and contracts fidelity honesty, truthfulness veracity fairness justicce duty to benefit others or promote good Beneficence requirement to do no harm Nonmaleficence decisions based on whether action is morally right or wrong, with no regard for consequences deontology decisions based on the greatest good for the greatest number utilitarianism five stages of grieving: shock and disbelief, developing awareness, restitution, resolution of the loss and recovery engel six tasks of grieving: recognize, react, recollect and reexperience, relinquish, readjust and reinvest rando four phases of grieving: numbness and denial of loss, emotional yerning for the lost loved one and protesting permanence of the loss, cognitive disorganization and emotional despair with difficulty functioning and emotinal despair with difficulty functioning and reintegration bowlby four stages of loss and adaptation outcry denial and intrusion working through and completion horowitz four tasks of grieving accept reality of the loss work through the pain of grief adjust to changes environment due to the loss and emotinally relocate and move on worden five stages of grief denial anger bargaining depression and acceptance kubler ross social withdrawal few or no relationships lack of closeness asociality Feelings of indifference toward people, activities, and events apathy tendency to speak little or to convey little substance of meaning (poverty of content) alogia restricted range of emotional feeling, tone or mood blunted effect Feeling no joy or pleasure from life or any activities or relationships anhedonia absence of anu facial expression that would indicate emotions or mood flat affect Absence of will, ambition, or drive to take action or accomplish tasks avolition compulsive skin picking, often to the point of physical damage an impulse control disorder dermatillomania/excoriation ritualistic or repetitive behaviors or mental acts that a person carries out continuously n attempt to neutralize anxiety compulsions compulsive nail biting onychophagia Recurrent and persistent thoughts, impulses, or images that are intrusive and unwanted that cause distress obsessions compulsive buying; possessions are acquired compulsively without regard for cost or need for the item oniomania compulsive hair pulling from scalp, eyebrow, or other parts of the body leaves patchy bald spots that the person tries to cconceal trichotillomania a preoccupation with an imagined or slight defect in physical appearance that causes significant distress for the individual and interferes with functioning in daily life body dysmorphic disorder involves excessive acquisition of animals or apparently useless things, cluttered living spaces that become uninhabitable and significant distress or impairment for the individual hoarding disorder people who feel overcomplete or alienated from a part of their body and desire amputation body identity integrity disorder False impressions that external events have special meaning for the person ideas of reference false sensory perceptions or perceptual experiences that do not exist in reality hallucinations Holding seemingly contradictory beliefs or feelings about the same person, event, or situation ambivalence continuous flow of verbalization in which other person jumps rapidly from one topic to another fights of ideas Fragmented or poorly related thoughts and ideas Associative looseness fixed false beliefs that have no basis in reality delusions Outlandish appearance or clothing; repetitive or stereotyped, seemingly purposeless movements; unusual social or sexual behavior bizarre behavior persistent adherence to a single idea or topic; verbal repetition of a sentence, word or phrase resisting attempts to change the topic perseveration Imitation of the movements and gestures of another person whom the client is observing echopraxia the client has a persistent or recurrent feeling of being detached from his or her mental processes or body or sensation of being in a dream like state in which the environment seems foggy or unreal. the client is not psychotic nor out of touch with reality depersonalization/ derealization disorder a group of symptoms such as stress, feeling sad or hopeless and physical symptoms that occur following a stressful life event, the reaction is stronger than would be expected for the event that occured adjustment disorder the client cannot remember important personal information. this category includes a fugue experience where the client suddenly moves to a new geographic location with no memory of past events and often the assumption of a new identity dissociative amnesia a disturbing pattern of behavior demonstrated by someone who has experienced a traumatic event for example, a natural disaster, a combat, or an assault begins 3 months or more following the trauma post traumatic stress disorder occur before the age of 5 in response to the trauma of child abuse or neglect called grossly pathogenic care. the child shows disturbed inappropriate social relatedness most situations. rather than seeking comfort from a select group caregivers to whom the child is emotionally connected to the child exhibits minimal social and emotional responses to others lacks a positive effect and may be sad irritable or afraid for no apparent reason reactive attachment disorder the client displays two or more distinct identities or personality states that recurrently take control of his or her behavior. this is accompanied by the inability to recall important personal information dissociative identity disorder diagnosis is appropriate when symptoms appear within the first month after the trauma and do not persist longer than 4 weeks acute stress disorder diagnosed when the client is severely ill and has a mixture of psychotic and mood symptoms. the signs and symptoms include those of both schizophrenia and mood disorder such as depression or bipolar disorder. the symptoms may occur simultaneously or may alternate between psychotic and mood disorder symptoms schizoaffective disorder the person with this diagnosis develops this delusion in the context of a close relationship with someone who has psychotic delusions, most commonly siblings, parent and child or husband and wife. the more submissive or suggestible person may rapidly improve if separated from the dominant person shared psychotic disorder distorted and bizarre thoughts, perceptions, emotions, movements and behavior. it cannot be defined as a single illness, rather, it is thought of as a syndrome or as a disease process with many different varieties and symptoms schizophrenia the client experiences the sudden onset of at least one psychotic symptom such as delusions , hallucinations, or disorganized speech or behavior which lasts from 1 day to 1 month. the episode may or may not have an identifiable stressor or may follow childbirth brief psychotic disorder characterized by marked psychomotor disturbance either excessive motor activity or virtual immobility and motionlessness. motor immobility may include catalepsy or stupor. excessive motor activity is apparently purposeless and not influenced by external stimuli. other behaviors include extreme negativism, mutism, peculiar movements, echolalia or echopraxia cataonia the client exhibits an acute reactive psychosis for less than the 6 months necessary to meet the diagnostic criteria for schizophrenia. if symptoms persist over 6 months the diagnosis is changed to schizophrenia. social or occupational functioning may or may not be impaired schizophreniform disorder the client has one or more non bizarre delusions that is the focus of the delusion is believable. the delusion may be persecutory, erotomanic, grandiose, jealous, or somatic in content. psychosocial functioning is not markedly impaired, and behavior is not obviously odd or bizarre delusional disorder the client belief that his or her organs aren't functioning or are rotting away or that some body part or feature is horribly disfigured or misshapen nihilistic delusions generally vague and unrealistic beliefs about the client health or bodily functions. factual information or diagnostic testing does not change these beliefs somatic delusions characterized by the clients claim to association with famous people or celebrities or the clients belief that he or she is famous or capable of great feats grandiose delusions often center around the second coming of Christ or another significant religious figure or prophet. religiosity involve the clients belief that television broadcasts, music or newspaper articles have special meaning for him or her referential delusions involve the clients belief that others are planning to harm him or her or are spying following rediculing or belittling the client in some way sometimes the client cannot define who these others are persecutory delusions involve the clients belief that his or her sexual behavior is known to others that the client is a rapist, prostitute or pedophile or is pregnant or that his or her excessive masturbation has led to insanity sexual delusions the nurse is assigned to care for a client admitted to the hospital after sustaining an injury from a house fire. the client attempted to save a negihbor involved in the fire but despite the clients efforts the neighbor died. which action would the nurse take to enable the client to work through the meaning of the crisis inquiring about the clients feelings that may affect coping Laboratory work is prescribed for a client who has been experiencing delusions. When the laboratory technician approaches the client to obtain a specimen of the client's blood, the client begins to shout, "You're all vampires. Let me out of here!" The nurse who is present at the time should respond with which question or statement are you fearful and think that others may want to hurt you the nurse enters a clients room and the client immediately demands to be released from the hospital. during review of the clients record, the nurse notes that the client was admitted 2 days ago for the treatment of an anxiety disorder and that the admission was voluntary one. the nurse reports the findings to the RN and expects that the RN will take which action contact the primary health care provider (PHCP) the nurse in a psychiatric unit is assigned to care for a client admitted to the unit 2 days ago. during review of the clients record the nurse notes that the admission was a voluntary one . based on this type of admission which would the nurse aspect to note the client will participate in the treatment plan the psychiatric nurse is greeted by a neighbor in a local grocery store. the neighbor says to the nurse. how is carol doing? she is my best friend and is seen at your clinic every week. which is the appropriate nursing response i cannot discuss any client situation with you following a group therapy session a client approaches the nurse and verbalizes a need for seclusion because of uncontrollable feelings. the nurse reports the findings to the RN and expects that the RN will take which action get a written prescription from the primary health care provider and obtain an informed consent the nurse is providing care for a client admitted to the hospital with a diagnosis of anxiety disorder. the nurse is talking with a client and the client says i have a secret that i want to tell you . you won't tell anyone about it will you. which is the appropriate nursing response i cannot promise to keep a secret a malpractice lawsuit was filed after a nurse restrained the client for screaming at and attempting to strike anyone who was within striking distance. the nurse followed agency procedures that were consistent with joint commission standard. for which reason is this malpractice lawsuit most likely to be unsuccessful the nurse did not breach duty disclosure of client information beyond the interdisciplinary team without consent of the client is a breach of confidentiality the physician has prescribed haldol 10 mg for a severely psychotic client. the client refuses the medication. which nursing intervention is an appropriate response accept the clients decision when is a nurse legally obligated to breach confidentiality if threats are made to an identifiable third party which nursing intervention constitutes false imprisonment the client has been "pesky" seeking the attention of nurses in the nurses station much of the day. now the nurse escorts the client to the room and tells the client to stay there or be put into seclusion a nurse has been caring for a gunshot victim has just died. various family and friends are present. one of the visitors privately disclose to the nurse that she and the client were having an illicit affair. which of the following is the best action by the nurse after learning of this relationship privately offer support to the visitor who was having the affair with the client an elderly woman who lives alone is beginning to have difficulty maintaining her household and performing daily tasks. the nurse asks her to identify someone who can help her. the woman replies i don't need help ive been managing for years. which of the following responses help the client shift from denial to consciously coping with her situation if you were to need help with your house who might you ask for help the bereaved client has worked through many process of grief with the urse. which of the following are eventful outcomes of the emotional dimension of grieving ? select all that apply the survivor begins to reestablish a sense of personal identity direction and purpose for living the survivor begins to gain independent and confidence the survivor develops new ways of managing life and new relationships which of the following losses are likely to result in disenfranchised grief? select all that apply the gay lover of a man who just died from aids a family whose long time pet snake has just died a nurse who has just witnessed the death of a patient a couple who has just experienced pregnancy loss which of the following persons are most likely experiencing complicated grieving? select all that apply an adult who insisted for many years that she hated her deceased parent the spouse of a person who died 7 years ago and visits the grave several times a day a driver whose spouse and children all died as a result of his driving drunk the parent of a child who died after the having left the child in a care on a hot day a young woman telephones the emergency department and loudly tells the nurse i've been raped please help me which of the following is the priority for the nurse to determine if the client was in a safe place her condition and if transportation is available the nurse is collecting assessment data on a client who is suspected to be a victim of violence. which assessment data would support the suspicion that the client is a victim of abuse? select all that apply there is a large amount of alcohol use in the home the client has few friends the client reports that the father was abusive during childhood which of the following are common characteristics of violent families regardless of the type of abuse that exists? select all that apply alcohol and other drug abuse intergenerational transmission social isolation abuse of power and control which of the following are common reasons why abused women remain with the abusive partner? select all that apply the abused person is personally and financially dependent on the abuser the abused person has low self esteem and defines her success as a person by the ability to make the relationship work the abused person believes that she is unable to function without her husband the abused person is afraid that the abuser will kill her if she tries to leave which of the following are typical characteristics of the perpetrator of intimate partner abuse ? select all that apply the perpetrator often believes that the partner is hs own property the perpetrator is often irrationally jealous even of his own children the perpetrator is emotionally immature and needy After an angry outburst, a client quickly appears more calm and rational. The nurse approaches the client. Which of the following is the most helpful response to the client at this time? what happened that got you so upset After an angry outburst, the client is tearful and remorseful. Which statement by the nurse would be most supportive? what could you have done when you first started to feel angry the client with a history of explosive outburst become angry and states i am really getting angry the nurse sees this as which of the following progress a client who suffers from frequent panic attacks describes the attack as feeling disconnected from hmself the nurse notes in the clients chart that the client reports expersincign depersonalization a nurse detects that a client is experiencing panic level anxiety. which interventions should be immediately implemented provide calm , brief, directive communication which of the following are cognitive behavioral therapy techniques that may be used effectively with anxious client? select that apply positive reframing decatastrophizing assertiveness training Before eating a meal, a client with obsessive-compulsive disorder (OCD) must wash his hands for 14 minutes, comb his hair 114 strokes, and switch the bathroom light on and off 44 times. What is the most appropriate goal of care for this client? gradually decrease the amount of time spent for performing rituals the nurse is aware that a person who repeatedly seeks cosmetic surgery to correct a perceived flaw in his or her appearance may have which of the following disorders body dysmorphic disorder The client has shown much improvement for obsessive-compulsive disorder (OCD). Which would be appropriate outcomes for a client with OCD? Select all that apply. the client will spend less time performing rituals the client will demonstrate effective use of behavior therapy techniques the nurse correctly identifies that which of a client with OCS's self soothing behaviors may involve self destruction of the body? select all that apply trichotillomania onychophagia dermatillomania a client has a history of schizophrenia controlled by haloperidol. during an assessment the nurse notes continuous restlessness. which medication would the nurse expect to be prescribed for this client benztropine mesylate a client is seen in the clinic with clinical manifestation of an inability to sit still and a rigid posture. as the nurse performs her assessment which of these side effects would be correctly identified akathisia a client with severe and persistent mental illness has been taking antipsychotic medication for 20 years. the nurse observes during their therapy session that the clients behavior includes repetitive movements of the mouth and tongue, facial grimacing and rocking back and forth. the nurse recognizes theses behaviors as indicative of which of the following tardive dyskinesia For a client taking clozapine (Clozaril), which of the following symptoms should the nurse report to the physician immediately as it may be indicative of a potentially fatal side effect? sore throat and malaise which of the following questions would best help the nurse to evaluate the effectiveness of antipsychotic medications for a client who has schizophrenia? select all that apply if the symptoms have not disappeared are you able to carry out your daily life despite the persistence of some psychotic symptoms have symptoms you were experiencing disappeared are you satisfied with your quality of life are you committed to taking the medication as prescribed During rounds, the depressed client is discovered to ha