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NUR101 / NUR 101 (Latest 2024 / 2025 Update) Health Assessment | Guide
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NUR101 / NUR 101 (Latest 2024 / 2025 Update) Health Assessment | Guide
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: NUR101 / NUR 101 (Latest Update) HealthAssessment | Guide
Which part of the cerebrum is responsible for emotions, affect, and awareness of self
- ANSWER frontal lobe
The nurse is caring for a patient who has a diagnosis of depression. This disorder is
associated with pathology in which part of the central nervous system? - ANSWER
Neurotransmitters
An insufficient amount of the neurotransmitter gamma aminobutyric acid (gaba) may
result in? - ANSWER Anxiety
The nurse is using CAGE screening tool, which stands for cut down, annoyed, guilty,
and eye opener. This tool is used to screen for which disorder? - ANSWER Alcohol
use
At what point does data for mental health assessment begin? when the nurse -
ANSWER First sees the patient
A 24-year-old male patient tells the nurse he has had no energy for two weeks, He
has trouble falling asleep. He states he has no appetite and no friends, The nurse
associates these manifestations with what mental health disorder? - ANSWER
Depression
Which patient may be experiencing anxiety? - ANSWER A man who calls the nurse
five times asking for instructions about how to take his new medication
a patient in the waiting room appears anxious and moves around the room cleaning
surfaces with a disinfectant cloth, This behavior is consistent which disorder? -
ANSWER obsessive compulsive disorder
Nurse taking a health history suspects the patient has altered mental status. Which
questions below are appropriate to ask when assessing mental status? - ANSWER
Do you know where you are?
"What does this phrase mean: 'A rolling stone gathers no moss?'"
"What would you do if a fire started in your home?"
If you bought a hat for $5.75 and gave the sales person $10.00, how much change
would you expect back?"
The nurse is obtaining the mental health history of a new patient. What should the
nurse include in this mental health history - ANSWER Medications the patient is
taking
A past health history
The patient's concept of self
,The nurse is performing a skin assessment on a patient in pain. Which skin layer
contains sensory fibers that react to touch, pain, and temperature? - ANSWER the
dermis
What findings does a nurse expect when inspecting and palpating a patient's nails? -
ANSWER The nail surface is smooth and round
A 49-year-old woman tells the nurse she is distressed by the presence of dark,
coarse hair on her face that has recently developed. What is the nurse's most
appropriate response to this patient? - ANSWER "Coarse dark hair could result
from hormonal changes such as from menopause."
The nurse is assessing an African-American patient for cyanosis. Cyanosis in dark
pigmented skin appears as a(n) - ANSWER ashen gray color to the skin.
The nurse is assessing a patient with chronic cardiopulmonary disease for nail
clubbing. Where should the nurse focus the exam? - ANSWER The angle of the
nail base
In assessing a patient's skin lesion, which finding by the nurse indicates a need for
further investigation - ANSWER The lesion bleeds easily when it is touched.
While inspecting the skin, a nurse notes that a lesion on the patient's upper right
arm. What is the best way to document the size of this lesion? - ANSWER Use a
centimeter ruler to measure the lesion.
During a health fair, which recommendation is appropriate as a primary prevention
measure to reduce the risk for skin cancer? - ANSWER Wear protective clothing
while in the sun
How does a nurse assess a patient's skin turgor? By - ANSWER pinching the skin
and watching the skin return to place.
Which questions would be appropriate to ask a patient when performing a symptom
analysis for a rash? - ANSWER What makes the rash worse?"
"What do you do to make your rash better?"
"When did the rash first start?"
"Describe what the rash looked like initially."
"Describe the sensation from the rash, dose it burn or itch?"
During symptom analysis, the nurse helps the patient distinguish between dizziness
and vertigo. Which description by the patient indicates vertigo? - ANSWER "It
seemed that the room was spinning around."
To assess jaw movement of an adult patient, the nurses uses which technique? -
ANSWER Placing two fingers in front of each ear and asking the patient to slowly
open and close the mouth
Which patient in the eye clinic should the nurse assess first? - ANSWER The
patient who complains of sudden loss of vision
, A patient complains of right ear pain. What findings does the nurse anticipate on
inspecting of patient's ears? - ANSWER Bulging and red tympanic membrane in the
right ear
What technique does a nurse use when palpating the right lobe of a patient's thyroid
gland using the anterior approach? - ANSWER Displaces the trachea to the right
with the left thumb.
The nurse is assessing a patient for recurring nosebleed. What could be a possible
cause of the nosebleeds? - ANSWER Snorting cocaine
What is the purpose of assessing a patient's vision confrontation? To assess for -
ANSWER peripheral vision
When performing an ophthalmoscopic examination, the nurse examines the patient's
right eye - ANSWER with the nurse's right eye and the patient's left eye with the
nurse's left eye.
The nurse is asking the patient to stick out his tongue and move it back and forth.
Which cranial nerve is the nurse testing? - ANSWER Hypoglossal nerve (CN XII)
What findings does the nurse expect when assessing the ears of a healthy adult? -
ANSWER Ratio of air conduction to bone conduction 2:1
Tympanic membrane pearly gray
Whispered words repeated accurately
Cerumen noted in the outer ear canal
Which findings does the nurse expect when assessing the mouth of a healthy adult?
- ANSWER Slight roughness on the dorsum of the tongue
Lips appear pink, smooth, moist and symmetric.
Teeth are white, yellow, or gray, with smooth edges.
The nurse is preparing to assess a patient's peripheral nervous sensory function.
Which assessment test would the nurse use? - ANSWER Light touch sensation
The nurse assesses the glossopharyngeal nerve (CN IX) by testing which reflex? -
ANSWER Gag reflex
Which statement regarding variations in neurologic functioning is true? - ANSWER
The function of the neurologic system is consistent across racial lines.
The nurse assesses an active reflex response. Which score should be documented?
- ANSWER 2+
While obtaining a symptom analysis from a patient who had a transient ischemic
attack, the nurse helps the patient distinguish between dizziness and vertigo. Which
description by the patient indicates dizziness? - ANSWER "I felt light-headed when
I stood up."
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