NUR 500 HEALTH ASSESSMENT FINAL EXAM
2024/2025 VERIFIED Q&A ( MSJ) SOLVED
Generalized Anxiety Disorder Scale
when asked a variety of questions about anxiety in the past two weeks:
0- not at all
1- several days
2- more than half the days
3- nearly every day
scores of 5, 10, or 15 total for the 7 questions shows mild, moderate, or severe
anxiety
Patient Health Questionnaire (for Depression)
when asked a variety of questions about depression symptoms in the past 2 weeks:
0 - not at all
1 - several days
2 - more than half the days
3 - nearly every day
,NUR 500 HEALTH ASSESSMENT FINAL EXAM
scores of 5 to 20 total for the 9 questions suggests mild to severe depression
Levels of Consciousness
1 - alert: awake; fully aware of stimuli and reacts appropriately
2 - lethargic: not fully alert; can be aroused with normal voice
3 - obtunded: sleeps most of the time; difficult to arouse; needs constant stimuli
4 - semi-coma: spontaneously unconscious; responds only to vigorous shake/voice
5 - coma: completely unconscious; no response to pain or other stimuli
Normal Pupil Size
3-5 mm
Tonsil Size
1+ visible
2+ halfway between tonsillar pillars an uvula
3+ touching uvula
4+ touching each other
Murmurs
,NUR 500 HEALTH ASSESSMENT FINAL EXAM
Grade 1 - barely audible
Grade 2 - clearly audible but faint
Grade 3 - easy to hear
Grade 4 - loud, with thrill
Grade 5 - very loud, with thrill
Grade 6 - heard with stethoscope lifted off of chest
Edema
1+ mild pitting
2+ moderate pittinng
3+ deep pitting; leg looks swollen
4+ very deep pitting; leg is grossly swollen
Strength
5 - full ROM against resistance
4 - full ROM against some resistance
3 - full ROM with gravity
2 - full ROM with no gravity
1 - slight contraction
0 - no contraction
, NUR 500 HEALTH ASSESSMENT FINAL EXAM
Reflexes
4+ very brisk; hyperactive; indicative of disease
3+ brisker than normal; might be disease
2+ average, normal
1+ diminished; only with reinforcement
0 no response
CN I
-olfactory nerve
-smell
CN II
-optic nerve
-sight
CN III
-oculomotor nerve
-opening eyelids
-pupil constriction/lens shape