NUR235 Exam 1 Study Guide Questions With Complete
Solutions
*Temp: 96-99.9*
Infants less than 6 months use
temporal
arterial
tympanic
axillary temp measurement *whether well or ill*
For infants under 90 days who are ill *do NOT use temporal
arterial*
Oral may be used at about 4 years old IF cooperative.
Correct Answers BP: Systolic:
1-7 = age in years + 90
8-18 = double age in years + 90
Diastolic:
1-5 years = 56
6-18 years = age + 52
Know when to screen BP (beginning at age 3 years or in high
risk)
Correct Answers HR:
Up to 3 months = 160-100
3 months-2 years = 150-80
2 years to 10 years = 110-70
10 years-adult = 90-55
,use apical in children younger than 2 years and count for 1
minute
athletic adolescents may have lower pulse rate.
Correct Answers Respiratory rates:
birth-6 months= 50-30
6 months-2 years=30-20
3-10 years=28-20
10-18 years=20-12
Appearance & Movement: Abnormal Correct Answers -
posture: tense, rigid, slumped, asymmetrical posture
---slumped posture is seen with depression or organic brain
disease
-gait: uncoordinated—staggering, shuffling, and stumbling
-motor movements: jerky, uncoordinated; tremors, tics, fast or
slow movements
---bizarre movements are seen with schizophrenia
---tense, fidgety, and restless behavior in anxious patients
-dress: clothes extra large or small and inappropriate for
occasion
---inappropriate dress is seen with depression, dementia,
Alzheimer disease, and schizophrenia
-hygiene: dirty, unshaven; dirty nails; foul odors
---poor hygiene is seen with depression, dementia, Alzheimer
disease, and schizophrenia
,---meticulous, finicky grooming in obsessive-compulsive
disorder
-facial expression:
---poor eye contact is seen in apathy or depression
---mask-like expression in Parkinson disease
---extreme anger or happiness in anxious clients
-speech: high pitched; monotonal; hoarse; very soft or weak
---slow, repetitive speech is present in depression or Parkinson
disease
---loud and rapid in manic phases
---irregular, uncoordinated speech in multiple sclerosis
---dysphonia in impairment of CN X
---dysarthria in Parkinson or cerebellar disease
---aphasia in lesions of dominant hemisphere
Appearance & Movement: Normal Correct Answers -posture:
relaxed, with shoulders back and both feet stable
-gait: smooth, coordinated movements; client alters position
occasionally
-motor movements: same as above
-dress: clothes fit and are appropriate for occasion and weather
-hygiene: skin clean, nails clean and trimmed
-facial expression: good eye contact, smiles/frowns
appropriately
, -speech: clear with moderate pace
Axillary route Correct Answers -CON: takes longer
Be able to assign a score on the Glasgow Coma Scale. Know
that the higher the number, the "better" the person is clinically.
Know there are scores that range from 3 to 15 Correct Answers
Use the Glasgow Coma Scale (GCS) for clients who are at high
risk for rapid deterioration of the nervous system
GCS score of 15 indicates an optimal level of consciousness
GCS score of less than 15 indicates some impairment of
consciousness. A score of 3, the lowest possible score, indicates
deep coma
Be able to label examples of "good" and "poor" documentation.
See Table 3-4. Correct Answers
Be able to use the Numeric Rating Scale 0-10 (for adults), and
the Faces Pain Rating Scale (for kids). Correct Answers
COLDSPA-What is the mnemonic for, how will you use it, be
able to label questions. Correct Answers
Compare objective and subjective data and be able to label
examples. Correct Answers
Define acute versus chronic pain. What is cancer pain? Correct
Answers *Acute pain:* usually associated with an injury with a
*recent onset* and duration of *less than 6 months* and usually
*lasts less than a month*
Solutions
*Temp: 96-99.9*
Infants less than 6 months use
temporal
arterial
tympanic
axillary temp measurement *whether well or ill*
For infants under 90 days who are ill *do NOT use temporal
arterial*
Oral may be used at about 4 years old IF cooperative.
Correct Answers BP: Systolic:
1-7 = age in years + 90
8-18 = double age in years + 90
Diastolic:
1-5 years = 56
6-18 years = age + 52
Know when to screen BP (beginning at age 3 years or in high
risk)
Correct Answers HR:
Up to 3 months = 160-100
3 months-2 years = 150-80
2 years to 10 years = 110-70
10 years-adult = 90-55
,use apical in children younger than 2 years and count for 1
minute
athletic adolescents may have lower pulse rate.
Correct Answers Respiratory rates:
birth-6 months= 50-30
6 months-2 years=30-20
3-10 years=28-20
10-18 years=20-12
Appearance & Movement: Abnormal Correct Answers -
posture: tense, rigid, slumped, asymmetrical posture
---slumped posture is seen with depression or organic brain
disease
-gait: uncoordinated—staggering, shuffling, and stumbling
-motor movements: jerky, uncoordinated; tremors, tics, fast or
slow movements
---bizarre movements are seen with schizophrenia
---tense, fidgety, and restless behavior in anxious patients
-dress: clothes extra large or small and inappropriate for
occasion
---inappropriate dress is seen with depression, dementia,
Alzheimer disease, and schizophrenia
-hygiene: dirty, unshaven; dirty nails; foul odors
---poor hygiene is seen with depression, dementia, Alzheimer
disease, and schizophrenia
,---meticulous, finicky grooming in obsessive-compulsive
disorder
-facial expression:
---poor eye contact is seen in apathy or depression
---mask-like expression in Parkinson disease
---extreme anger or happiness in anxious clients
-speech: high pitched; monotonal; hoarse; very soft or weak
---slow, repetitive speech is present in depression or Parkinson
disease
---loud and rapid in manic phases
---irregular, uncoordinated speech in multiple sclerosis
---dysphonia in impairment of CN X
---dysarthria in Parkinson or cerebellar disease
---aphasia in lesions of dominant hemisphere
Appearance & Movement: Normal Correct Answers -posture:
relaxed, with shoulders back and both feet stable
-gait: smooth, coordinated movements; client alters position
occasionally
-motor movements: same as above
-dress: clothes fit and are appropriate for occasion and weather
-hygiene: skin clean, nails clean and trimmed
-facial expression: good eye contact, smiles/frowns
appropriately
, -speech: clear with moderate pace
Axillary route Correct Answers -CON: takes longer
Be able to assign a score on the Glasgow Coma Scale. Know
that the higher the number, the "better" the person is clinically.
Know there are scores that range from 3 to 15 Correct Answers
Use the Glasgow Coma Scale (GCS) for clients who are at high
risk for rapid deterioration of the nervous system
GCS score of 15 indicates an optimal level of consciousness
GCS score of less than 15 indicates some impairment of
consciousness. A score of 3, the lowest possible score, indicates
deep coma
Be able to label examples of "good" and "poor" documentation.
See Table 3-4. Correct Answers
Be able to use the Numeric Rating Scale 0-10 (for adults), and
the Faces Pain Rating Scale (for kids). Correct Answers
COLDSPA-What is the mnemonic for, how will you use it, be
able to label questions. Correct Answers
Compare objective and subjective data and be able to label
examples. Correct Answers
Define acute versus chronic pain. What is cancer pain? Correct
Answers *Acute pain:* usually associated with an injury with a
*recent onset* and duration of *less than 6 months* and usually
*lasts less than a month*
