HEALTH ASSESSMENT E-HANDOUTS (CBRC)
SUBJECT: Fundamentals of Nursing
TOPIC: Health Assessment
SUBTOPIC: Initial Data Gathering
OBJECTIVE: After reading this, you will be able to:
a. Determine the steps in in initial data assessment of
clients seeking care
b. Develop the standard skills in communicating and
establishing the nurse-patient relationship
Discussion
What is Health Assessment?
 Health Assessment is the data gathering of an
individual in all aspects including the spiritual and
emotional state.
What is the nurse’s role in health assessment?
 ADVOCATE: A nurse advocate is a nurse who
works on behalf of patients to maintain quality of
care and protect patient’s rights. They intervene
when there is a care concern, and following the
proper channels, work to resolve any patient care
issues.
Steps in Data Assessment
1. Establish Rapport
2. Obtain Health History
3. Assess level of consciousness
4. Gather equipment needed
5. Perform Hand washing
Chief Complaint
In your patient’s own words, document the chief
complaint. The chief complaint may be elicited by
asking one of the following questions:
 So, tell me why you have come here today?
 Tell me what your biggest complaint right now?
 What is bothering you the most right now?
 If we could fix any of your health problems right
now, what would it be?
 What is giving you the most problems right
now?
 If your patient has more than one complaint,
discuss which one is the most troublesome for
them and document the complaints in order of
importance as determined by the patient
(Jarvis,2012)
Present Health Status
Obtaining information about the present health status
allows the nurse to investigate current complaints. The
mnemonic PQRST, utilizes a structured format for
information gathering, including evaluation of pain, and
provides an efficient methodology to communicate with
other healthcare providers. Use PQRST to assess each
symptom and after any intervention to evaluate any
changes or response to treatment (Jarvis, 2012).
PQRST
 P= Provocative or Palliative
What makes the symptom(s) better or worse?
 Q = Quality
Describe the symptom(s).
 R= Region or Radiation
Where in the body does the symptom occur? Is there
radiation or extension of the symptom(s) to another
area of the body?
 S= Severity
On a scale of 1-10, (10 being worst) how bad is the
symptom(s)? Another visual scale may be
appropriate for patients that are unable to identify
with this scale.
 T= Timing
Does it occur in association with something else (i.e.
eating, exertion, movement)?
Past Health History
It is important to ask questions about your patient’s past
health history. The PHH should elicit information about
the patient’s childhood illnesses and immunizations,
accidents or traumatic injuries, hospitalizations,
surgeries, psychiatric or mental illnesses, allergies, and
chronic illnesses. For women, include history of
menstrual cycle, how many pregnancies and how many
births (Jarvis,2012).
Family History
Current Health Status: Information collected should also
include details about your patient’s personal habits such
as smoking or drinking, nutrition, cholesterol, and if
there is a history of heart disease or hypertension.
Medications: Obtain a list of current medications,
including dose and frequency, as well as reason for
taking them. Remember to ask the patient about over the
counter medications, vitamins, and herbal supplements
(Jarvis, 2012).
 HEALTH ASSESSMENT DREX Notes (CBRC) 2. DILATED EYES:
Drugs taken:
Nurse-Patient Relationship = PROFESSIONAL
 Amphetamines, Methamphetamines,
Characteristics: “HHH” = Head (Cognition), Hands Cocaine or Crack, Hallucinogens (i.e.
(Skills), Heart (Attitude) LSD or mushrooms), Opiates
Goal: INDEPENDENCE OF THE CLIENT (prescription painkillers), Heroin,
FOCUS (ROLE): “ROLE mo then HANDWASH VS” Marijuana, Speed
 Rapport, Obtaining Health History, Level of 3. RED EYES:
Consciousness, Equipment Drugs taken:
Hand washing & Vital Signs (VS)  Marijuana, Cocaine or Crack,
HEALTH HISTORY ASSESSMENT (SAMPLE): Benzodiazepines (i.e. Xanax),
 Symptoms (FELT by the patient) / Signs Depressants (i.e. Alcohol or Sedatives)
(OBSERVED by the nurse/doctor), Allergies,
Medications, Past Medical History, Last Oral SIGN OF IMPENDING DEATH:
Intake, Events leading to the illness or injury Constant Dilation of Pupils

I. RAPPORT V. HAND WASHING

 Reassurance, Active Listening, Posture: 1. Medical:
Gesture – affect, Privacy & Empathy ,  Uses SOAP, Not less than 10 seconds
Observe Layman’s term, Respect Culture,  Recommendation: 20 seconds or more
Touch 2. Surgical
II. Types of Touches:  Uses STERILIUM and BETADINE,
a. Functional (BEST for patients) = Not less than 5 minutes
PROFESSIONAL
b. Social = POLITE
c. Friendship = WARMTH QUESTION: WHY DOES SURGICAL
d. Love = INTIMACY HANDWASHING MAKES YOUR HANDS DRY?
e. Sexual = AROUSAL  Microorganisms die out on DRY surroundings.
III. HEALTH HISTORY  This is to dehydrate the microorganisms’ nuclear
 Primary Data: Patient envelope (nucleus) which makes the RNA &
 Secondary Data: Family or other Support DNA of the microorganisms be destroyed.
Persons, Healthcare Professionals, Records
and Reports, Laboratory and Diagnostic Medical Assessment V.S. Nursing Assessment
Analyses, and Relevant Literatures. 1. ASSESSMENT is the part of medical practice;
Past, Present, Family, Future the PROCESS is the SAME, OUTCOMES DIFFER.
IV. LEVEL OF CONSCIOUSNESS (LOC) 2. BOTH ASSESSMENTS should COMPLEMENT,
1st Level: ALERT (Awake and Conversant without NOT CONTRADICT
tangentiality, circumstantiality, and looseness of 3. Medical Assessment
associations)  for Dx and Tx
2nd Level: CONFUSION (Unclear thoughts) 4. Nursing Assessment:
3rd Level: DISORIENTATION (Cannot recall the  focuses on patient as a person to the
place, date and time) optimal level of wellness (HOLISTIC
4th Level: LETHARGIC (Responsive upon VERBAL APPROACH)
approach)  contribute to IDENTIFICATION of
5th level: OBTUNDED (Responsive upon TACTILE MEDICAL PROBLEMS
approach) COMPREHENSIVE RECORD of the PT …..
HEALTH HISTORY!
6th Level: STUPOR (Responsive upon PAIN is
HEALTH HISTORY involves….. PAST &
inflicted)
CURRENT!
7th Level: COMA (Not responsive)
HEALTH HISTORY is focused on….. MEDICAL
1. CONSTRICTED EYES: DX & TX AND HOLISTIC CARE!
Drugs taken:
 Heroin, Morphine, Oxycodone,
Fentanyl, Methadone, Codeine,
Hydrocodone
Comparison Nursing & Medical Diagnoses
NURSING DX MEDICAL DX
Ineffective Airway
Pneumonia
Clearance
Disturbed Body Image Amputation
Risk for Unstable
Blood Glucose Diabetes Mellitus
Impaired Urinary
Elimination Post-Op Prostatectomy
Self-Care Deficit: Cerebrovascular
Dressing & Gowning Accident
5 STAGES OF NURSING PROCESS (ADPIE)
 Assessment, Diagnosis (Nanda), Planning (Uses
SMART), Implementation, Evaluation
SMART:
 Specific (simple, sensible, significant)
 Measurable (meaningful, motivating)
 Achievable (agreed, attainable)
 Relevant (reasonable, realistic and
resourced, results-based)
 Time Bound (time-based, time limited,
time/cost limited, timely, time-sensitive)
FDAR CHARTING
 FOCUS
 DATA
 SUBJECTIVE = SYMPTOMS or COVERT
cues include the client’s feelings and
statement about his or her health problems
and are best recorded as direct quotations
from the client.
 OBJECTIVE = SIGNS or OVERT cues,
OBSERVABLE and MEASURABLE
(quantitative) data that are obtained through
observation, standard assessment techniques
during the physical examination and
laboratory and diagnostic testing.
 ACTION
 RESPONSE
DEFINITIONS and TERMINOLOGIES
 HEALTH – is a state of complete physical,
mental and social well-being and not merely the
absence of disease or infirmity (World Health
Organization, WHO).
 ASSESSMENT – is a systematic, dynamic
process by which the nurse through interactions
with client, significant others and health care
provides, collects and analyzes data about client
(American Nurses Association, ANA).
 HEALTH HISTORY – is a collection of
SUBJECTIVE data that includes information on
both the client’s past and present health status.
 PHYSICAL EXAMINATION – provides
OBJECTIVE data for identifying problems and
making diagnoses.
 ASSESSMENT – is a systematic and deliberate
process of gathering the information regarding
client’s health.
 INSPECTION – involves the visual examination
of the body.
 PALPATION – use of tactile sensation for
identifying characteristics of skin and superficial
tissues.
 PERCUSSION – use of tapping with fingers on
the body to determine the quality of sound.
 AUSCULTATION – involves listening the
sounds within the body either by ears or
stethoscope.
TYPES OF ASSESSMENT:
 COMPREHENSIVE HEALTH ASSESSMENT:
COMPLETE PHYSICAL EXAMINATION and
HEALTH HISTORY.
 ONGOING PARTIAL ASSESSMENT:
Conducted at REGULAR INTERVALS
DURING CARE OF THE PATIENT.
 FOCUSED ASSESSMENT: EXAMINATION
OF A BODY AREA
 EMERGENCY ASSESSMENT: TYPE OF
RAPID ASSESSMENT conducted to
IDENTIFY THE POTENTIALLY FATAL
CONDITIONS.
CULTURAL SENSITIVITY
Client’s health beliefs, use of alternative
therapies, nutritional habits, relationship
with family and comfort with the nurses’
physical closeness during an examination
and history taking MUST BE
CONSIDERED.
COMPONENTS OF Nx HEALTH HISTORY
 Biographic Data
 Reason For Seeking Care/ Chief Complaint
 History Of Present Illness
 Past Health History
SUMMARY:
a. Immunization Status, Known Allergies,
Childhood Illness, Adult Illness, Psychiatry
Illness, Injuries- burns, fractures, head
injuries, Hospitalization, Surgical and
Diagnostic Procedures, Medication History,
Use of alcohol and other Drugs.
  Family History (BALD CHASM) BODY TYPES
 Blood Pressure is High, Arthritis, Lung  Ectomorph = Skinny; Difficulty in gaining
Diseases, Diabetes, Cancers, Heart weight
Diseases, Alcoholism, Stroke, Mental  Mesomorph = Naturally muscular; easy gain
Illnesses (Bipolar, Depression, etc.) and loses weight
 Review of Systems  Endomorph = Round; Difficulty in losing
 Subjective information about what the weight; slower metabolism
patient feels or sees with regard to major
systems of the body. BODY SHAPES
o General Constitutional Symptoms  Rectangle, Triangle, Hourglass, Inverted
 Lifestyle (SHADE) Triangle, Round
 Sleep and Rest Pattern, Habit, Activity
and Exercise Pattern, Diet, Elimination PHYSICAL EXAMINATION
Problems
A. INSPECTION
 Obstetric History
 Sight & Smell
 menstrual pattern: regular/irregular
 FACTORS:
 history of pregnancy, labor, puerperium
a) Positioning
and complications if any
b) Lighting (Visualization)
 Socio-Cultural History
 Home Environment, Family Situation,  for EYE Assessment (PERRLA and VISION):
Client’s Role in the Family, Smoking: o SIZE of NORMAL PUPIL = 3-7 mm
Packs Per Year = No. of packs per day  MYDRIASIS - >7 mm; Dilated
x no. of years smoking  Give MYOPIC DRUGS!
 Psychosocial History  MIOSIS
 Refers to assessment of dimensions such  constricted
as self-concept and self-esteem as well  ANISOCORIA - unequal pupils
as usual sources of stress and client’s o SHAPE = EQUALLY round
ability to cope. o NORMAL REACTION TO LIGHT
 Sources of support for clients in crisis,  Constriction = well lit area
such as family, significant others,  Dilation = dim or dark area
religion, or support groups, should be o NORMAL REACTION TO ACCOMODATION
explored. (NEAR OBJECT)
 Psychological History - Constriction
 Occupational and Environmental History o DIRECT RESPONSE
 If the light or object is shone in the right eye, the
4 PHASES OF NURSING INTERVIEW right pupil constricts.
1. Preparatory Phase (Pre Orientation) o CONSENSUAL RESPONSE
2. Introduction Phase (Orientation)  If the light or object is shone produces constriction
3. Working Phase on the right pupil, the left pupil also constricts.
4. Termination Phase o LEGAL BLINDNESS = 20/200
o MYOPIA = Nearsightedness (CONCAVE)
NONVERBAL COMMUNCATION o HYPERROPIA = Farsightedness (CONVEX)
 Haptic = Touch o DIM LIT ROOM IS USED
 Proxemics = Distance o SNELLEN CHART (Standard)
 Public = 12 Ft and beyond o Rose nBaum CHART (14 inches away from the
 Social = 8-12 ft eyes).
 Personal = 4-8 ft c) Exposure
 Intimate = 0-18 in (1 ½ ft)  Expose ONLY the body part that is to be currently
 Chronemics = Time examined.
 Paralanguage = Voice d) Comparison
 Kinesics = Body Language  Before INSPECTION:
a. Establish Rapport
b. Good Lighting
c. Consent
  INDIRECT AUSCULTATION - uses
 IAPePa (“I Am Peter Parker”) = ABDOMEN instrument (stethoscope)
Reasons: For STETHOSCOPE:
 To avoid alteration of assessment bowel sounds  belL = LOW PITCH sounds
 To detect presence for BRUITS (signifies AAA) - For BRUITS, ABNORMAL HEART
 NRSNG MGT: Put sign “DO NOT PALPATE!” SOUNDS (S3 and S4), BLOOD
 IPaPEA = GENERAL PRESSURE
B. PALPATION  diapHragm = HIGH PITCH sounds
 TYPES: - For NORMAL and ABNORMAL
 LIGHT PALPATION BOWEL SOUNDS
 Surface, Parallel alignment of hand to LISTENING to sounds produced by the
body surface. body:
 DEEP PALPATION  Heart, Blood Vessels, Lungs,
 1-3 inches (2.5-7.5 cm) deep, Delicate Abdomen
procedure, Requires supervision BODY MASS INDEX
 FINGER PADS = Fine Discrimination  Measurement of body fat based on weight and
 PALMAR/ULNAR = Thrills, height
Vibrations, Fremitus  BMI = WEIGHT (kgs)/ HEIGHT (m2)
 To know what size, shape or  Lbs/2.2 = ____kg
texture of a body area or organ. BMI CATEGORIES
 DORSAL = Temperature SEVERELY <16
 Other Purposes for PALPATION: UNDERWEIGHT
Temperature, Texture (Smoothness and UNDERWEIGHT 16-18.4
roughness of the skin), Moisture, Organ
NORMAL 18.5-24.9
size and location, Rigidity or Spasticity,
Vibration, Position, Size, Presence of OVERWEIGHT 25-29.9
lumps or masses OBESE >30
C. PERCUSSION
 Sense of hearing is used VITAL SIGNS
 Striking approach of a surface A. TEMPERATURE
 TYPES:  Temperature center= HYPOTHALAMUS
a. Direct (uses Plexor  ROUTES:
Dominant/Dominant hand) a) ORAL = MOST ACCESSIBLE and
-striker MOST CONVENIENT
b. Indirect (uses Pleximeter/Non- Contraindications: Vomiting & Seizure
dominant Hand) -Bimanual b) RECTAL = MOST ACCURATE (core
 Being strike on the interphalangal joints. body) Contraindications: Diarrhea,
 SOUNDS: Hemorrhoids, Cranial Nerve 10
a. Resonant (air filled lungs) - Hollow, low- c) TYMPANIC = FASTEST (2-3 seconds)
pitched sounds Contraindications: Otitis Media
b. Hyperresonance (colds, emphysematous d) AXILLA = LEAST ACCURATE;
lung – hyperinflated – too much air inside SAFE Bath for 30 minutes
alveolar sacs of the lungs)  CLEANING THERMOMETERS
- Booming, louder-pitched sounds  BEFORE USING: BULB to
- NORMAL for PEDIATRIC LUNG. STEM
c. Tympanic (air filled Stomach) - Drum-  AFTER USING: STEM to
like BULB
d. Dull (Diaphragm, heart, liver, spleen) -  TYPES OF FEVER
“thud-like” , Dense tissue a) Remittent = Wide Fluctations (above
e. Flat (Bones, muscles, tumors) - Extremely normal temp.)
dull (due to highly dense tissue) b) Constant = Minimal Fluctuations
D. AUSCULTATION (above normal temp.) Ex. 39.1 – 39.4
TYPES: – 39.7
 DIRECT AUSCULTATION - uses c) Intermittent = On and Off Fever Ex.
unaided ear (not using an instrument) 39.1 – 39.4 – 38.5
 d) Relapsing = 1-2 days of short febrile dimension of thoracic
episode cavity; elevates lower
B. PULSE ribs)
 NORMAL: 60-100 bpm
 BRADYCARDIA = <60 bpm  NORMAL BREATH SOUNDS:
 TACHYCARDIA = >100 bpm  BRONCHIAL - High-pitched sounds that is
 RADIAL PULSE is felt on the wrist, just under heard over the tracheobronchial tree.
the thumb.  BRONCHOVESICULAR - Moderate-pitched
 APICAL PULSE (Point of Maximal Impulse – sounds that are heard over the bronchioles.
PMI) LOCATION: 5th Intercostal space at the  VESICULAR - Low-pitched sounds that is
left midclavicular line. heard over the lung fields.
 SITES (6 PULSE POINTS/SITES (CBARFP)
– font color RED):  COMMON ABNORMAL BREATH SOUNDS:
a) Temporal, Carotid, Brachial, Apical, a) RALES (CRACKLES)
Radial, Femoral, Posterior Tibial,  Small, clicking, bubbling, or rattling sounds in
Popliteal, Pedal the lungs.
 PULSE DEFICIT  Believed to occur when air opens closed air
 Apical – Peripheral spaces.
 NORMAL = 0  TYPES:
 PULSE VOLUME  FINE
a) +0 = ABSENT - heard during late inspiration and may sound
b) +1 = THREADY/WEAK like hair rubbing together.
c) +2 = NORMAL - indicates an interstitial process, such as
d) +3 = ABOVE NORMAL pulmonary fibrosis or congestive heart failure.
e) +4 = BOUNDING - WHAT’S INSIDE? FLUID!!!
 PULSE OXIMETER  COARSE
 NORMAL = 95-100% - are somewhat louder, lower in pitch, and last
 THREATENING = <70% longer than fine crackles. 
 SITES: FINGERS, TOES, EARLOBES, - Sound like opening a Velcro bag.
NOSETIPS, FOREHEAD – Use of - indicates an airway disease, such as
PATCHES bronchiectasis.
C. RESPIRATION - WHAT’S INSIDE? PHLEGM!!!
 NORMAL: 12-20 bpm b) FRICTION RUB
 BRADYPNEA = <12 bpm  A raspy breathing sound caused by
 TACHYPNEA = >20 bpm inflammation of the tissues around your
 (-) APNEA = Cessation of Breathing lungs.
 Difficulty of Breathing (DOB) = Dyspnea  is usually “grating” or “creaky.”
 ONE CYCLE (1 RESPIRATION) = 1  Indicates a sign of pleurisy (inflammation
INSPIRATION THEN 1 EXPIRATION of the pleural tissues around the lungs).
c) STRIDOR
Muscles of Inspiration Muscles of Expiration  Wheeze-like sound heard when a person
A. Accessory A. Quiet Breathing breathes.
Sternocleidomastoid  Superficial
Expiration results from passive, elastic recoil of the grating sounds
lungs, rib cageheard
and during
(elevates sternum) diaphragm. inspiration and expiration, which are not
relieved by coughing.
Scalenes Group (elevates B. Active Breathing  Usually occurs due to a blockage of airflow
upper ribs) in trachea or in the back of the throat.
C. Principal Internal intercostals EXCEPT interchondral
d) Rhonchipart (pull ribs down)
External intercostals – Abdominals  Sounds that resembles snoring.
interchondral part of (pull ribs down, compress abdominal contents,
 They thus,occur
pushes diaphragm
when up) or air flow
air is blocked
internal intercostals becomes rough through large airways.
(elevates ribs) e) Wheezing
Diaphragm Quadratus Lumborum  High-pitched, musical sounds produced by
(dome descends, thus (pull ribs down) narrowed airways.
increasing vertical
  Common people having acute asthma -HOLE IN CUFF: Pressure leaks too fast to
attacks. reliably record
-CARDIAC ARRYTHMIAS: Erratic readings
 BREATHING PATTERNS: E. PAIN
a) BIOT’S RESPIRATIONS- Irregular  <6 months (Acute) = Fast Pain
cluster of breath, Very shallow  >6 months (Chronic) = Slow Pain
breathing  Pain Threshold
b) CHEYNE STOKES- Deep to shallow  Amount of pain stimulation required to
with periods of apnea feel pain.
c) KAUSSMAUL’S- Labored breathing,  Pain Tolerance
Very deep breathing  Amount of duration of pain
D. BLOOD PRESSURE  Types of Pain
 PULSE PRESSURE  Radiating Pain- Pain that travels from one
 SYSTOLIC-DIASTOLIC: NORMAL body part to another.
30-40 mmHg difference  Referred Pain- The pain you feel in one part
 STROKE VOLUME of your body is actually caused by pain or
 Amount of blood ejected per heartbeat injury in another part of your body.
NORMAL: 55-100 mL/heartbeat  Intractable Pain- Pain is constant and
Blood Pressure Systolic Diastolic excruciating, - Type of pain that can't be
Classification BP BP controlled with standard medical care.
NORMAL <120 <80  Phantom Pain-  Pain that feels like it's coming
and from a body part that's no longer there.
Prehypertension 120-139 80-89  PQRST Pain Assessment:
or  Precipitating/Predisposing
 Quality
Stage 1 HTN 140-159 90-99
 Stabbing (e.g. Angina), Crushing
or
(e.g. Myocardial Infarction),
Stage 2 HTN ≥ 160 ≥ 100 Pounding (e.g. Hypertension),
 CONSIDERATIONS IN TAKING BP: Gnawing (e.g. Peptic Ulcer Disease),
 The arm must be at heart level. Knife-like (e.g. AAA, ruptured
 Duration-Deflation (15 minutes rest appendix)
before taking another BP)  Region/Radiation
 Distance – antecubital fossa (2 finger  Severity (use of Pain Scale)
breadths)  Time (Onset; Frequency)
 Proper wrapping of the BP cuff is F. HEARING
advised to avoid false high BP reading. 1. WEBER TEST: Test can detect
 REPEATING BP IS ONLY ONCE! unilateral conductive and sensorineural
hearing loss. Place base of struck tuning
fork on bridge of forehead, nose or
teeth.
NORMAL No lateralization
 FACTORS THAT AFFECT BP: UNILATERAL Lateralization to affected s
CONDUCTIVE a hearing loss where the
INCREASES BP: SMOKING, DRINKING HEARING LOSS outer ear and middle ear int
COFFEE, EXERCISE, EATING UNILATERAL Lateralization to normal o
DECREASES BP: ALCOHOL, HEMODIALYSIS SENSORINEURA  is caused by damage to th
 CONSEQUENCES OF COMMON ERRORS L HEARING LOSS nerve.
and ARTIFACTS  SENSORINEURAL- Involving the
-CUFF TOO WIDE: Falsely low reading inner ear, cochlea, or the auditory nerve.
-CUFF TOO NARROW OR SMALL: Falsely  CONDUCTIVE- involving any cause
high reading that limits the amount of external sound
-CUFF TOO LOOSE: Falsely elevated reading from gaining access to the inner ear (e.g.
-CUFF OVER A JOINT: Less likely to compress cerumen impaction)
artery
  MIXED- A combination of conductive -Spinal cord injury, Frontal release
and sensorineural hearing loss signs, Posturing
2. RINNE TEST:  SCALE:
  Used primarily to evaluate loss 0 ABSENT
of hearing in one ear. 
1+ HYPOACTIVE
 Air conduction must be better
than bone conduction. 2+ NORMAL
 Place base of struck tuning fork 3+ HYPERACTIVE
on the mastoid bone 4+ HYPERACTIVE
 Have patient indicate when WITH CLONUS
sound is no longer heard 5+ SUSTAINED
 Move fork (held at base) beside CLONUS
ear and ask if now audible  GALLEAZZI TEST (ALLIS SIGN)
NORMAL AC>BC (Patient can hear fork at ear) - A test to assess hip displacement
CONDUCTIVE BC>AC (Patient will not hear fork at ear) (Congenital or injury)
HEARING LOSS - Unequal knee length

G. MUSCULOSKELETAL  TYPES OF CLUBFOOT:

 ROM TEST
 5 = Full ROM with against
gravity, full resistance
 4 = Full ROM with against
gravity, some resistance
 3 = Full ROM with against
gravity, some resistance
 2 = Full ROM with against
gravity, Gravity is eliminated
 1 = Small-flickering contraction
 0 = No contraction
 Inflammation is characterized by
5 cardinal signs:
1) RUBOR (REDNESS)
2) CALOR (INCREASED HEAT)
3) TUMOR (SWELLING)
4) DOLOR (PAIN)
5) FUNCTIO LAESA (LOSS OF
FUNCTION)
REFLEXES
0 NO RESPONSE
1 DIMINISHED
2 NORMAL
3 ABOVE NORMAL;
BRISK
4 HYPERACTIVE
 REFLEXES:
 DEEP TENDON REFLEXES:
-Biceps Reflex (C5/C6),
Brachioradialis Reflex (C6),
Triceps Reflex (C7), Patellar
Reflex (L4), Achilles Tendon (S1)
 PLANTAR RESPONSE
 REFLEX TESTED
SPECIAL SITUATIONS
 Talipes Equinovarus (CLUB
FOOT) - Internal rotation of foot
and contracted Achilles tendon
(Plantar flexion).
-MOST COMMON: Talipes
Varus, Talipes Valgus, Talipes
Equinus, Talipes Calcaneus
H. INTEGUMENTARY
 PARTS: Hair, Nails , Skin
 LAYERS OF SKIN:
 Epidermis
- contains cells (melanin) that
produce pigment and protect
immune system.
- Avascular (absence of blood
vessels)
- PARTS: COLUGRASPIBA
 Stratum corneum,
Stratum lucidum, Stratum
granulosum, Stratum
spinosum, Stratum basale
 Dermis
- Contains nerve endings, oil
and sweat glands, and hair
follicles. -Vascular
- PARTS: Papillary & Reticular
 Subcutaneous Tissue
- Made up of fat, connective
tissue, and larger blood vessels.
 VITILIGO - Long-term condition
where pale white patches develop on the
skin.
 ALBINISM- Group of inherited
disorders that result in little or no
production of the pigment melanin,
IN which determines the color of the skin,
hair and eyes.
 BIRTHMARKS- are marks that result e)Skin atrophy- The degeneration
of excessive accumulations of melanin and thinning of the epidermis and
which is present at birth or appears dermis.
shortly after birth. f) Fissure- is a crack or tear in
 SKIN CHANGES the skin.
 Pallor- Unusual lightness of skin g) Lichenification- Thick, leathery
color skin, usually the result of constant
- may be caused by reduced blood flow scratching and rubbing. 
and oxygen or by a decreased  SPECIAL
number of red blood cells. a) Purpura- Purple-colored spots and
 Cyanosis- Bluish color to the skin patches that occur on the skin, and
or mucous membrane is usually due in mucus membranes, including the
to a lack of oxygen in the blood. lining of the mouth.
 Jaundice- Yellow staining of the b) Telangiectasia- Dilatation of small
skin and sclerae (the whites of the blood vessels (arterioles, capillaries,
eyes) by abnormally high blood venules), often multiple in
levels of the bile pigment bilirubin. character.
 Erythema- Redness of the skin that c) Comedone- The primary sign of
results from capillary congestion. acne, consisting of a widened hair
- can occur with inflammation, as in follicle filled with keratin skin
sunburn and allergic reactions to debris, bacteria, and sebum (oil).
drugs.  NAILS
 SKIN LESIONS NORMAL ABNORMAL
 PRIMARY CONVEX CLUBBING OF
a) Macule- Flat, distinct, discolored SHAPE FINGERNAILS
area of skin less than 1 centimeter  Caused by lack
(cm) wide. of oxygenation
b) Papule- Solid, elevated lesion with and heart
no visible fluid which may be up to problems.
½ cm. in diameter.
c) Vesicle- A small fluid-filled blister DEGREE KOILONYCHIA
on the skin. OF ANGLE (spoon nails)
d) Pustule- a small collection of pus in - refers to abnormally
the top layer of skin (epidermis) or thin nails (usually of the
beneath it in the dermis. hand) which have lost
e) Urticaria- Raised, itchy areas of their convexity,
skin that are usually a sign of an becoming flat or even
allergic reaction. concave in shape.
f) Bullae- A fluid-filled sac or lesion - a sign of hypochromic
that appears when fluid is trapped anemia, especially iron-
under a thin layer of your skin. deficiency anemia.
 SECONDARY  MOUTH
a) Crust- are dried sebum, pus, or  TEETH:
blood usually mixed with epithelial  NORMAL NO. OF
and sometimes bacterial debris. ADULT TEETH = 32
b) Ulcer- A break in skin or mucous  DECIDUOUS = 20
membrane with loss of surface  ABNORMALITIES
tissue, disintegration and necrosis  GINGIVITIS
of epithelial tissue, and often pus. - Inflammation of the
c) Necrosis- The death of body tissue. gums.
d) Erosion- Loss of some or all of the  GLOSSITIS
epidermis (the outer layer) leaving a - Inflammation of the
denuded surface.  tongue.
 STOMATITIS
- Mouth sores
 MACROGLOSSIA
 - Abnormal enlargement of Scurvy is a disease characterized by soft, bleeding gums
the tongue (gingivitis); along with loose teeth, pinpoint
hemorrhages, muscle and joint pain and poor wound
 THORAX healing.
 NORMAL AP Diameter = 2:1 4. Specific prevention focuses on removing or
ABNORMALITIES reducing the levels of the risk factors. Mrs. Assassin was
ANTERIOR POSTERIOR scheduled for Cervista Test by Nurse Sage. This action
BARREL KYPHOSIS is an example of:
CHEST - Excessive ANSWER: Cervista Test is an example of
- air retention/ outward SECONDARY prevention.
air trapping curvature of the It focuses on early identification of health problems and
- Emphysema spine prompts intervention to alleviate health problems. Its
(PINK - In CPR, goal is to identify individuals in an early stage of disease
PUFFERS) kyphosis patients process and to limit future disability.
patients use donut 5. According to Florence Nightingale, health is a
pillows. state of being well and using every power the individual
possesses to the fullest extent. Which of the following
PIGEON LORDOSIS individuals appear to have taken on the sick role?
CHEST - Forward ANSWER: An employer who is ill and says “I won’t
- Pectus curvature of the be able go to the office today.”
carinatum spine. 6. The World Health Organization defines health
- caused by - Commonly seen as the state of complete physical, mental, and social
Marfan in pregnant well-being, and not merely the absence of disease.
Syndrome or women. During which stage of illness will we expect Rogue to
rickets. relinquish the dependence role?
FUNNEL SCOLIOSIS ANSWER: Recovery or Rehabilitation
CHEST - Lateral During the Recovery and Rehabilitation stage, the client
- Pectus curvature of the is expected to relinquish the dependent role and resume
excavatum spine. former roles and responsibilities.
- caused by 7. Personal responsibility and sense of control are
Marfan the key concepts for promotion of health. As the nurse
Syndrome or reviews the client’s level of knowledge after several
rickets. health-teaching sessions, she determined that the client
still fails to follow the information provided. The nurse
must respond by:
HEALTH ASSESSMENT: DIAGNOSTIC TEST ANSWER: Reevaluate the client’s readiness to
NOTES change
A client's readiness to change is often influenced by his
1. Based on the paradigm of nursing, health refers or her perception of importance and confidence.
to the holistic level of wellness that the person Importance refers to the personal value of change.
experiences. Sniper identifies the nursing domain in a Confidence relates to the mastering of the skills needed
paradigm which includes: to achieve the behavior and the situations in which
ANSWER: Person, situation, environment, nursing behavior change will be challenging to the client.
2. Primordial prevention focuses on preventing the 8. A nurse is giving a bed bath to a client who is on
emergence of risk factors. Primary prevention aimed at strict bed rest. To increase venous return, the nurse
health promotion and includes: bathes the client’s extremities by using:
ANSWER: Immunization is PRIMARY prevention. ANSWER: Long, firm strokes from distal to
Cancer screening is SECONDARY prevention. proximal areas
Self-administration of steroid is an example of Long, firm strokes in the direction of venous flow
TERTIARY prevention. promote venous return when the extremities are bathed.
3. To check if a client has a possible Vitamin C Circular strokes are used on the face.
deficiency, or scurvy, the nurse must make sure to Short, patting strokes and light strokes are not as
examine the client’s: comfortable for the client and do not promote venous
ANSWER: Gingiva. return.
9. Andrea, a critically-ill patient, who has been in
deep coma for couple of days, needs eye care. The nurse
then organizes the necessary equipment to be used.
Which of the following actions if made by the nurse
would warrant an immediate intervention from the nurse
supervisor?
ANSWER: Wiping the eye with saline and cotton
balls from the outer to the inner canthus.
Proper wiping technique moves debris away from the
eye, prevent reinfection or contamination of the eye, and
protects the tear ducts.
10. Andrea, a mother who delivered via the normal
delivery, with episiorraphy has been complaining of
mild discomfort. As the nurse assigned to take care of
her, which of the following should you omit in the plan
of care?
ANSWER: Avoiding sitz bath
11. When performing oral care on a comatose client
the nurse should:
ANSWER: Place the client in a side-lying position,
with the head of the bed lowered
12. A registered nurse is teaching a nurse orienteer
in their unit about proper bed making. Which of the
following interventions should not be part of her
teaching?
ANSWER: For occupied bed, the side rail on the
opposite side must be down to easily make a mitered
corner.
A side rail provides safety and allows the client to assist.
The side rail on your side must be down when mitering
corner for the client’s safety.
13. Florence Nightingale defined nursing as “the act
of utilizing the environment of the patient to assist him
in his recovery.” Thief, 14 years, wants to be a nurse
someday as she idolizes the nurse assigned to care for
her. She asked her nurse, “What is nursing?” All of the
following are not inappropriate responses to the query,
except?
ANSWER: Diagnosing, treating, prescribing
medication and doing minor surgery
Nursing is defined as assisting clients in the performance
of activities contributing to health, its recovery or
peaceful death that clients will perform unaided, of they
had the necessary will, strength or knowledge, Assisting
clients toward independence (Virginia Henderson)
Nursing is the diagnosis and treatment of human
response to actual or potential health problems (ANA
1980)
14. The respiratory therapist is doing the Allen’s test
erroneously if he performs which of the following?
ANSWER: Withdraws blood if the pinkness of the
hand returns within 9 seconds
15. Nurse Sarah is caring for a client with renal
failure. Blood gas results indicate a pH of 7.30, a PCO2
of 32 mmHg, and a bicarbonate concentration of
20mEq/L. Which of the following laboratory values
would Nurse Sarah expect to note?
ANSWER: Potassium level of 5.2 mEq/L
Normal values:
Sodium 135-145 mEq/L
Magnesium 1.5-2.5 mEq/L
Potassium 3.5-5.0 mEq/L
Phosphorus 2.4 to 4.1 mg/dL
16. Nurse Sarah is caring for a client after a
bronchoscopy and biopsy. Which of the following signs
if noted in the client should be reported immediately to
the physician?
ANSWER: Bronchospasm
Bronchospasm and/or laryngospasm, an irritation of the
airways and/or vocal cords may interfere with a
bronchoscopy.
17. Nurse Sarah is caring for a female client. Which
of the following actions is the most essential that nurse
Sarah must ensure prior to Chest x-ray?
ANSWER: Ask about the first day of the last
menstruation.
18. Which of the following actions is the most
essential that Nurse Sarah must ensure prior to the
pulmonary angiography of her patient?
ANSWER: Assess for allergies to iodine, seafood or
other dyes.
19. Nurse Sarah is preparing to obtain a sputum
specimen from a client. Which of the following nursing
actions will facilitate obtaining the specimen?
ANSWER: Having the client take three deep breaths
20. Nurse Sarah is conducting preoperative teaching
with a client about the use of an incentive spirometer in
the postoperative period. Nurse Sarah would include
which piece of information in discussion with the client?
ANSWER: The best results are achieved when the
head of the bed is elevated 45 to 90 degrees
21. Nurse Sarah’s client is unable to use the
incentive spirometer device. In counseling the client, the
first advice of nurse Sarah would be to:
ANSWER: Start slowly and gradually increase
volume over several sessions.
22. Nurse Sarah must include all of the following
proper instructions in deep breathing and coughing
exercises to post-operative clients except:
ANSWER: The client should perform this exercise at
least twice every shift.
23. Sister Callista Roy proposed the Adaptation
Model. Who among the following theorist consider and
utilize nature and environment in the healing process?
ANSWER: Florence Nightingale
24. A nurse orienteer states imperfectly to Nurse
Sarah the proper way of doing chest physiotherapy
(CPT) during their post-conference if she specifies:
ANSWER: “If the client is receiving a tube feeding,
finish the feeding and begin doing the CPT in high
fowlers’ position”.
25. Nurse Sarah has assisted a physician with the
insertion of a chest tube. Nurse Sarah monitors the client
and notes fluctuation of the fluid level in the water seal
chamber after the tube is inserted. Based on this
assessment, which of the following actions would be
most appropriate?
ANNSWER: Continue to monitor, for this is an
expected finding
The water-seal chamber is filled with sterile water to the
level specified by the manufacturer. You should see
fluctuation (tidaling) of the fluid level in the water-seal
chamber; if you don't, the system may not be patent or
working properly, or the patient's lung may have re-
expanded.
26. Nurse Sarah is caring for a client with a chest
tube. Nurse Sarah turns the client to the side, and the
chest tube accidentally disconnects. The initial nursing
action is to:
ANSWER: Place the tube in a bottle of sterile water
Creating a temporary water seal until a new drainage
system is set up. A chest tube should never be clamped,
except on orders from a physical or qualified
practitioner.
27. Nurse Sarah is assisting a physician with the
removal of a chest tube. Nurse Sarah will appropriately
instruct the client to:
ANSWER: Deep breathe, exhale, and bear down
When the chest tube is removed, the client is asked to
perform the Valsalva maneuver (take a deep breathe,
exhale and bear down). The tube is quickly withdrawn,
and an airtight dressing is taped in place. An alternative
instruction is to ask the client to take deep breath and
hold the breath while the tube is removed.
28. Nurse Sarah has observed a client self-
administer a dose of Albuterol (Ventolin) via MDI.
Within a short period of time, the client begins to
wheeze loudly. Nurse Sarah interprets that this is due to:
ANSWER: Paradoxical bronchospasm, which must
be reported to the physician
Get emergency medical help if you have any of these
signs of an allergic reaction to albuterol: hives; difficult
breathing; swelling of your face, lips, tongue, or throat.
29. Nurse Sarah has an order to give a client
Albuterol (Ventolin) two puffs, and Budesonide
(Fulmicort), two puffs, by MDI. Nurse Sarah administers
the medication by giving the:
ANSWER: Albuterol first and then the Budesonide
Inhaled B2-adrenergic agonists are first line therapies for
rapid symptomatic improvement of bronchoconstriction.
These medication relax smooth muscles and reduce local
congestion, reducing airway spasm, wheezing, and
mucus production.
30. Nurse Sarah is assigned to take care of an
asthmatic patient; she must administer the medications
containing a bronchodilator and a corticosteroid through
nebulization. Nurse Sarah is performing this procedure
imperfectly if:
ANSWER: After nebulization, rinse the bottle with
tap water to remove all remaining solution and allow
to dry
31. An oxygen delivery system is prescribed for a
client with Chronic Obstructive Pulmonary Disease
(COPD) to deliver a precise oxygen concentration.
Which of the following types of oxygen delivery
systems would Nurse Sarah anticipates to be prescribed?
ANSWER: Venturi mask
This device uses different size adaptors to deliver a fixed
or predicted FiO2. The FiO2 delivered depends on the
flow rate and/or entrainment port size. It is used for
patients who have COPD when an accurate FiO2 is
essential and carbon dioxide buildup must be kept to a
minimum. Humidifiers usually are not used with this
device. ( 60% to 100%)
32. Nurse Sarah is caring for a client with
emphysema. The client is receiving oxygen. Nurse Sarah
assesses the oxygen flow rate to ensure that it does not
exceed:
ANSWER: 2L/min
O2 therapy may be prescribed but must be used
cautiously. The goal of O2 therapy is to maintain the
PaO2 between 50 and 60 mmhg. The initial liter flow is
usually 1-3L/min.
33. A group of nursing students is discussing about
the descriptions related to non-rebreather mask. The
student incorrectly states the proper description of non-
rebreather mask to nurse Sarah if she identified which of
the following?
ANSWER: “The valves should open during
inhalation and close during exhalation”.
With Non-rebreather masks, make sure valves are open
during expiration and closed during inhalation to prevent
drastic decrease in FIO2 (fraction of inspired oxygen)
34. Madeleine Leininger proposed that nursing is
learned humanistic and scientific profession and
discipline which is focused on the human care
phenomena and activities in order to support, facilitate,
or enable individuals or groups to maintain or regain
their well-being (Transcultural Nursing). Who among
the following theorists conceptualized the framework for
psychiatric nursing, wherein a nurse must established a
therapeutic relationship with the client?
ANSWER: Hildegard Peplau
Hildegard Peplau is known for her theory on
Interpersonal Relations in Nursing.
Betty Neuman is known for the Health Care Systems
Model.
Imogene King is known for the Goal Attainment Theory
Lydia Hall is known for the Care-Core-Cure Model
35. Which nursing action by Nurse Sarah is
essential to prevent hypoxemia during tracheal
suctioning on her patient?
ANSWER: Administering 100% oxygen to reduce
the effects of airway obstruction during suctioning.
Hyperoxygenation is performed bt increasing the intake
of oxygen immediately prior to suctioning and when
appropriate after suctioning (Pedersen et al., 2008) and
helps reduce the occurrence of hypoxemia. Hyper
oxygenation (pre-oxygenation) before suctioning offers
some protection from a drop in arterial blood oxygen.
36. A client requires tracheal suctioning through the
nose. Which nursing action by Nurse Sarah would be
incorrect?
ANSWER: Suctioning for 20 seconds
37. In verifying and ensuring the placement of an
endotracheal tube, Nurse Sarah must know that the
following are necessary EXCEPT:
ANSWER: Use maximal occlusive pressure when
inflating the cuff in order to create a seal
Verifying Tube Placement. Verify the distal tip marking
on endotracheal tube and immediately after ET tube is
inserted, placement should be verified. The most
accurate ways to verify placement are by checking end-
tidal carbon dioxide levels and by chest x-ray. Assess for
breath sounds bilaterally, sound over the gastric area,
symmetric chest movement, and air emerging from ET
tube. Auscultate over the trachea for presence of air leak.
38. Nurse Sarah is caring for a client immediately
after removal of the endotracheal tube following radical
neck dissection. Nurse Sarah reports which of the
following signs immediately if experienced by the
client?
ANSWER: Stridor
Auscultate breath sounds as needed. In the immediate
postoperative period, place stethoscope over the trachea
to assess for Stridor. Abnormal breath sounds may
indicate ineffective ventilation, decreased perfusion, and
fluid accumulation. Stridor a harsh, high-pitched sound
primarily heard on inspiration indicates airway
obstruction.
39. Nurse Sarah is changing the tapes on a
tracheostomy tube. The client coughs and the tube is
dislodged. The initial nursing action is to:
ANSWER: Grasp the retention sutures to spread the
opening
40. A nurse is taking care of a client with
Rheumatoid Arthritis and was ordered to collect feces
for occult blood exam. Which of the following
statements if made by the client need for further
instructions?
ANSWER: “I may continue taking my Arcoxia 72
hours prior to collection of the sample”.
41. The client being seen in a physician’s office has
just been scheduled for a barium swallow the next day.
The nurse writes down which of the following
instructions for the client to follow before the test?
ANSWER: Fast for 8 hours before the test
The patient should maintain NPO status after midnight.
Food and fluid in the stomach prevents barium from
accurately outlining the GI tract, and the radiographic
result may be misleading.
42. A nurse is taking care of client who has just
been scheduled for a barium swallow the next day. The
nurse must provide the following instructions for the
client after the test except:
ANSWER: Expect that the bowel movement not to
occur within 2 days
The evening before the BE, administer cathartics such as
magnesium citrate (laxative) or other cathartics
designated by institution policy. After the BE study,
assess the patient for excavation of the barium. Retained
barium may cause a hardened impaction (increase OFI).
Stool will be light colored until all barium has expelled.
43. The client has undergone
esophagogastroduodenoscopy. The nurse places highest
priority on which of the following items as part of the
client’s care plan?
ANSWER: Assessing for the return of the gag reflex
The patient is usually given a preprocedure intravenous
(IV) sedative such as midazolam (Versed). The patient
pharynx is anesthetized by spraying it with lidocaine
hydrochloride (Xylocaine). Therefore do not allow the
patient to eat or drink until gag reflex returns (usually
about 2 to 4 hours).
44. The nurse determines that the client needs
further information if the client makes which of the
following statements?
ANSWER: “I’m glad I don’t have to lie still for this
procedure”.
45. The science of Unitary Human Being and
Principles of Homeodynamics are proposed by Martha
Rogers. According to Benner’s stages of nursing
expertise, a nurse with 2 to 3 years of experience who
can coordinate multiple complex nursing care demands
is at which stage?
ANSWER: Competent
Novice - No experience, governed by rules, limited and
inflexible, task oriented.
 Advance Beginner - Demonstrates marginally
acceptable performance
Competent - has 2-3 yrs. of experience, consciously
plans nursing care
Proficient - >3-5 yrs. of experience, perceives the
situation as a whole rather than parts
Expert - Has intuitive grasp of nursing situation.
46. The nurse has given post-procedure instructions
to a client who underwent colonoscopy. The nurse
determines that the client needs further instructions if the
client stated that:
ANSWER: It is all right to drive once the client has
been home for an hour or so
47. The nurse is caring for a client who is receiving
total parenteral nutrition (TPN) via a central line. Which
nursing intervention specifically would provide
assessment data related to the most common
complication related to TPN?
ANSWER: Monitoring the temperature – infection
Infection is always a concern because the high
concentration of dextrose contained in TPN provides
excellent medium for bacterial growth. Strict aseptic
technique is important while changing bottles containing
the TPN solution, tubing, filters, and dressings. Because
the catheter is in major blood vessel, any infection would
spread rapidly throughout the body.
48. A nurse is preparing to change the TPN solution
bag and tubing. The client’s central venous line is
located in the right subclavian vein. The nurse asks the
client to do who of the following most essential items
during the tubing change?
ANSWER: Take a deep breath, hold it, and bear
down.
The client should be asked to perform the Valsalva
maneuver during tubing changes. This helps avoid air
embolism during tubing changes. The nurse asks the
client to take a deep breath, hold it, and bear down. If the
IV line is on the right, the client turns his or her head to
the left. This position will increase intrathoracic
pressure. Options A and C are inappropriate and could
cause the potential for an air embolism during the tubing
change.
49. A nurse is making initial rounds at the beginning
of the shift. The TPN bag of an assigned client is empty.
Which of the following solutions readily available on the
nursing unit should the nurse hang until another TPN
solution is mixed and delivered to the nursing unit?
ANSWER: 10% dextrose in water
50. A nurse is inserting a nasogastric tube in an
adult client. During the procedure, the client begins to
cough and has difficulty of breathing. Which of the
following is the most appropriate nursing action?
ANSWER: Pull back on the tube and wait until the
respiratory distress subsides
51. The nurse checks for residual before
administering a bolus tube feeding to a client with
nasogastric tube and obtains a residual amount of 150
mL. What is the appropriate action for the nurse to take?
ANSWER: Hold the feeding.
52. A nurse is preparing to administer medication
through a nasogastric tube that is connected to suction.
To administer accurately, the nurse would:
ANSWER: Clamp the nasogastric tube for 30
minutes following administration of the medication
53. A diabetes nurse educator is providing health
teaching regarding the proper method of blood glucose
determination through skin puncture. The nurse needs to
reinforce the teaching if the client identifies which of the
following statements?
ANSWER: “I should select the central tip of the
finger which has more dense blood supply”.
54. What is the most important intervention the
nurse can perform to prevent nosocomial infections
associated with enteral nutrition?
ANSWER: Wearing clean gloves when handling the
feeding system
55. The nurse is assessing a stoma prolapse in a
client with colostomy. The nurse would observe which
of the following if the stoma prolapsed occurred?
ANSWER: Protruding stoma
A prolapsed stoma is one which the bowel protruded
through the stoma.
A stoma retraction is characterized by sinking of the
stoma.
Ischemia of the stoma would be associated with dusky
or bluish color
. A stoma with a narrowed opening at the level of the
skin or fascia is said to be stenosed.
56. Goal Attainment Theory is proposed by
Imogene King. A student nurse asked her clinical
instructor about Benner’s “Proficient” nurse level. The
C.I. did not incorrectly answer the question when she
stated that the nurses under this level:
ANSWER: Perceives situation as a whole rather than
in terms of parts
57. The client with a new colostomy is concerned
about the odor from stool in the ostomy drainage bag.
The nurse teaches the client to include which of the
following foods in the diet to reduce odor?
ANSWER: Yogurt
The client should be taught to include deodorizing foods
in the diet, such a beet greens, parsley, buttermilk, and
yogurt.
Spinach also reduces odor but is a gas forming food as
well.
Broccoli, cucumbers, and eggs are gas forming foods.
58. The nurse instructs the ileostomy client to do
which of the following as part of essential care of the
stoma?
ANSWER: Cleanse the peristomal skin meticulously
The peristomal skin must receive meticulous cleansing
because the ileostomy drainage has more enzymes and is
more caustic to the skin than colostomy drainage.
Foods such as nuts and those with seeds will pass
through the ileostomy. The client should be taught that
these foods will remain undigested.
The area below the ileostomy may be massaged if
needed if the ileostomy becomes blocked by high fiber
foods.
Fluid intake should be maintained to at least six to eight
glasses of water per day to prevent dehydration.
59. The client has just had surgery to create an
ileostomy. The nurse assesses the client in the immediate
post-operative period for which of the following most
frequent complication of this type of surgery?
ANSWER: Fluid and electrolyte imbalance
60. A client has an order for “enemas until clear”
before major bowel surgery. After preparing the
equipment and solution, the nurse assists the client into
which of the following positions to administer the
enema?
ANSWER: Left-lateral Sim’s position
Ask the client to lie on the side (preferably the Left-
lateral Sim’s position). The colon’s position within the
body makes this position the most effective.
61. You are to perform a complete physical
assessment to Mr. Mogul Khan, 48 years old, diagnosed
with a certain chronic obstructive pulmonary disease.
You expect to hear which of the following sounds during
percussion of his lung fields?
ANSWER: Hyper resonance
Flat Sound- Extremely dull (Elicited in Muscles and
bones)
Dull Sound- Muffled (elicited in liver, spleen and heart)
Resonant- Hallow (elicited in a normal lung);
Hyperresonant- Booming (elicited in lungs with COPD)
Tympany - Drum-like (elicited in Stomach)
62. You were assigned to care for a patient who has
suffered from second-degree burns all over his upper
extremities just last night. During examination, you
noted circumscribed, oval masses, filled with serous
fluids that are more than 1 cm. You properly document
this as:
ANSWER: Bullae
Pustule- Circumscribed elevation of skin filled with
serous fluid and pus
Bullae- thin walled blister greater than .5 cm with serous
fluid
Vesicle- translucent circumscribed filled with serous
fluid or blood lesser than .5 cm
Wheal- collection of edema fluid
63. Nurse Gyrocopter was assigned to assist a
patient who was admitted due to a certain central
nervous system disorder. While he’s reviewing his
patient’s chart, he reads: “Right pupil – 7 mm in
diameter, left pupil – 4 mm in diameter.
ANSWER: The patient has anisocoria
Anisocoria is a condition where the pupil of one eye
differs in size from the pupil of the other.
Normal size of pupil is 3-7mm
64. After Nurse Tinker has performed visual
assessment, using a Snellen chart, to her patient Drow
Ranger, she documented that this patient’s visual acuity
is 20/40. She understands that:
ANSWER: The patient can read at distance of 20 feet
away from the Snellen chart, that an individual with
normal vision can read from 40 feet distance.
A normal eye has a vision of 20/20.
The definition of legal blindness is 20/200.
The numerator is the distance of the patient from the
Snellen chart while the denominator is the distance of an
individual with a normal vision.
65. Windrunner, 27, is admitted after a massive car
accident. Nurse Necrolyte, is to assess this patient’s
pupil reactions and accommodation. Which of the
following indicates an abnormal response?
ANSWER: Windrunner’s pupil constricts when
looking at the far object.
66. Nurse Slayer was tasked to perform a
cephalocaudal assessment to her patient on the EENT
ward. After the examination, she documented the
findings accordingly. Upon reading the chart, one entry
reads: “Weber negative”. This can be interpreted as:
ANSWER: A normal finding
67. According to the American Nurses Association,
nursing is the diagnosis and treatment of human
responses to actual or potential health problems. The
World Health Organization (WHO) defines health as:
ANSWER: A state of complete physical, mental, and
social well-being
The World Health Organization (WHO) takes a more
holistic view of health. Its constitution define health as
"a state of complete physical, mental and social well-
being and not merely the absence of disease or infirmity"
68. Mr. Lifestealer, 57 years old, has been suffering
from emphysema for five years. He was admitted in the
hospital due to exacerbation of his disease. Upon
assessment his chest, you expect to find?
ANSWER: Barrel chest
Pectus Carinatum is expected in patients with Vitamin
D. Deficiency (condition: Rickets)
 Pectus Excavatum is congenital and is expected to have
a depressed sternum
Barrel Chest is expected in COPD which is an effect of
the Carbon Dioxide accumulation in the lungs leading to
the increasing of its AP diameter.
AP diameter is greater than or equal to Transverse
Diameter.
69. You are to examine your patient’s breath sounds
admitted for general check-up. Which of the following
sounds will be considered normal?
ANSWER: Soft-intensity, low-pitched sounds heard
at the base of the lungs.
Soft intensity, low pitched sounds heard at the base of
the lungs is called Vesicular sounds which are a normal
finding.
Option B is Crackles
Option C is Wheezes
Option D is Ronchi. These are all abnormal sounds.
70. You are to perform abdominal assessment to
your patient who has been complaining of pain on the
left upper quadrant. You know that to properly execute
the procedure, you should:
ANSWER: Palpate the left upper quadrant last
71. A patient was rushed into the Emergency
Department who was complaining of abdominal pain.
Based on initial assessment, appendicitis is suspected.
The nurse expects that the patient will be pointing pain
on which of the following abdominal regions?
ANSWER: Right inguinal
72. The nurse is preparing a Snellen chart for the
physical examination. This is used to assess which of the
following cranial nerve/s?
ANSWER: Cranial nerve II
Cranial Nerve Number II is responsible for the sense of
sight, using the Snellen Chart is the most appropriate test
for visual acquity
CN III, IV and VI are for extraoccular movement
VII is for Facial expressions 2/3 anterior 73. portion of
the tongue (taste).
73. Mr. Grand Magus was admitted to the hospital
after falling from the stairs. Upon examination, Nurse
Neruvian called the patient’s name and that’s the only
time he opened his eyes. The patient raised his legs and
hands when asked to do so. The patient was also
oriented to time, place, and person. The patient’s GCS
score is:
ANSWER: M: 6, V: 5, E: 3
Eye( 4- spontaneous,3- to verbal command, 2- to pain, 1-
no response)
Verbal(5- Oriented and Conversant, 4- disoriented and
conversant, 3-Inapprpriate words, 2- Incomprehensible,
sound 1- No response)
Motor(6- to verbal command, 5-to localized pain, 4-
flexes and withdraws, 3- Decorticate, 2- decerebrate, 1-
No response)
74. Mrs. Naga Siren, who is suspected to have
developed a sensory ataxia, had a positive Romberg’s
test. The positive result means that:
ANSWER: The patient cannot maintain balance
while standing with eyes closed
Romberg’s test is a test of imbalance. The patient is
instructed to stand on both feet and be instructed to close
the eyes. A heavy sway or misbalance would mean a
positive Romberg’s test.
75. When asked about the place where he lives
during a mini-mental status exam, Mr. Warlock said,
“It’s been a while since I went home. When I’m home, I
can do so many things. I can paint, I can sing, dance, and
watch movies. I want to go home now.” After what he
has said, he was not able to provide the information
requested. The client apparently has:
ANSWER: Tangentiality
76. You will receive this injection in a clinic or
hospital setting as part of a medical test. Edrophonium
(Tensilon) is used for the diagnosis of myasthenia gravis
because this drug will cause a temporary increase in:
ANSWER: Muscle strength
Tensilon, an anticholinesterase drug, causes temporary
relief of symptoms of myasthenia gravis in clients who
have the disease and is therefore an effective diagnostic
aid.
77. During the previous few months, a 55 year old
woman felt brief twinges of chest pain while working in
her garden and has had frequent episodes of indigestion.
She comes to the hospital after experiencing severe
anterior chest pain while raking leaves. Her evaluation
confirms a diagnosis of stable angina pectoris.
Evaluation of the effectiveness of nitroglycerin SL is
based on:
ANSWER: Improved cardiac output
78. As per R.A. 9173, promotion of health and
prevention of illness are the primary responsibilities of
nurses as independent practitioners. As a member of
health team, nurses shall collaborate with other health
care providers for the curative, preventive, and
rehabilitative aspects of care, restoration of health,
alleviation of suffering, and when recovery is not
possible, towards a peaceful death. Nurse Monk is
conducting a series of promotive and preventive
programs for a group of clients. All of the following
activities are not considered promotive nursing actions,
except?
ANSWER: Implementation of PD 491
PD 996 is the Expanded Program on Immunization
RA 9288 is the Newborn Screening Act, both are
preventive nursing actions
Only PD 491 is a promotive nursing action which is the
Nutrition Program.
79. A client with heart failure is receiving digoxin
(Lanoxin) and will continue taking the drug after
discharge. Before giving the medication, the nurse
should assess the patient’s:
ANSWER: Apical heart rate
Because digoxin slows the heart rate, the apical pulse
should be counted for 1 minute before administration. If
the apical rate is below 60, digoxin should be withheld
because its administration could further depress the heart
rate.
80. A client is receiving heparin sodium and
warfarin sodium (Coumadin) concurrently for a partial
occlusion of the left common carotid artery. The client
expresses concern about why both heparin and
Coumadin are needed. The nurse’s explanation is based
on the knowledge that the plan:
ANSWER: Provides anticoagulant intravenously
until the oral drug reaches its therapeutic level.
81. The drug that the nurse should expect the
physician to order if symptoms of warfarin (Coumadin)
overdose are observed would be:
ANSWER: Vitamin K
Warfarin depresses prothrombin activity and inhibits the
formation of vitamin K dependent clotting factors by the
liver. Its antagonist is vitamin K which is involved in
prothrombin formation.
82. Which statement should the nurse make when
teaching the client about taking oral glucocorticoids?
ANSWER: “Take your medication with meals.”
83. The nurse administers neomycin to a client with
hepatic cirrhosis to prevent the formation of:
ANSWER: Ammonia
Neomycin destroy intestinal flora, which breaks down
protein and in the process gives off ammonia. Ammonia
at this time is poorly detoxified by the liver and can
build up to toxic levels.
84. What is the rationale that supports multidrug
treatment for clients with tuberculosis?
ANSWER: Multiple drugs reduce development of
resistant strains of the bacteria
Use of a combination of anti-tuberculosis drugs slows
the rate at which the organism develops drug resistance.
Combination therapy also appears to be more effective
than single-drug therapy. Regimens that use only single
drugs result in the rapid development of resistance and
treatment failure.
85. Jose, a recent graduate of BS Nursing is
attending a review class for the November 2014 board
exam. The topic of the lecture is Pharmacokinetics. Jose
likes to know more about the concept of
Pharmacokinetics so he asks the lecturer about the
importance of knowing the Pharmacokinetics of a
particular drug. The lecturer will mention the following
importance of Pharmacokinetics:
ANSWER: Pharmacokinetics will explain the details
of the chemical interaction between the drug and the
target cell, tissue or organ
Pharmacokinetics does not discuss the mechanism of
action of the drug to the body, instead it describes how
the drug moves in the body, and therefore it can help in
determining the serum drug concentration
86. The following situations demonstrate an
application of a Nurses’ knowledge about the
Pharmacodynamics of a given drug, EXCEPT:
ANSWER: The Nurse instructs a diabetic patient to
avoid rubbing the injection site after SubQ injection
of insulin
87. Nurse Kelly noticed that the dose of the opioids
given P.O. is higher than that of the I.M. route. Nurse
Kelly will be correct in her interpretation by stating that:
ANSWER: If the drug is given by the oral route is
will be subjected to first pass metabolism.
A higher dose of a drug is required if the drug undergoes
first pass effect because the drug will be subjected first
to metabolism in the liver, therefore inactivating the
drug before it reach the systemic circulation
88. If a highly protein bound drugs like Diazepam
(98% protein bound), Lorazepam (92% protein bound)
or Valproic Acid (92% protein bound) is given to a
patient with a liver disease, you will expect:
ANSWER: An increased amount of unbound drugs
in the blood, therefore more drugs are released into
the systemic circulation, increasing its effect
89. Primary level of prevention includes health
promotion and illness prevention. Clown Gypsy Group
of Companies establishes a physical exercise area in the
workplace and encourages all employees to use it. This
is an example of which level of prevention?
ANSWER: Primary prevention
90. A patient is taking a drug that is known to be
toxic to the liver. The patient is being discharged to
home. What teaching points related to liver toxicity of
the drug that the nurse needs to teach the patient to
report to the physician:
ANSWER: Body malaise, change in the color of the
stool
91. Which of the following will NOT be included in
your health teachings when dealing with the excretion of
drugs?
ANSWER: An acid ash diet will increase the
excretion of weak acidic drugs
An acid ash diet will acidify the urine therefore
promoting the excretion of alkaline drugs like atropine.
An alkaline ash diet will alkalinize the urine therefore
promoting the excretion of acidic drugs
92. Nurse Michelle is studying different classes of
anti-hypertensive, and notes their respective mechanism
of action. Which of the following sets of drugs produce
an effect of enzyme inhibition to exert their therapeutic
action of decreasing the blood pressure?
ANSWER: Captopril, Perindopril, Enalapril
Losartan, Valsartan and Telmisartan are Angiotensin II
receptor antagonist
Metoprolol, Atenolol and Propranolol are beta receptor
antagonist
Methyldopa and Clonidine are Alpha 2 receptor
agonists, these drugs do not directly affect enzymes, but
reacts with receptors causing or inhibiting a response
Captopril, Perindopril and Enalapril are Angiotensin
Converting Enzyme Inhibitors that prevents the
formation of Angiotensin II that can cause
vasoconstriction
93. Nurse Marilyn is taking care of end stage cancer
patient. She will be administering Morphine Sulfate and
Tramadol for pain. She is aware that it can result to
additive interaction, causing greater pain control. She is
aware of the other potential advantage of this type of
interaction which includes:
ANSWER: Lower doses of each drug can be
administered, which can decrease the probability of
adverse reactions
94. A client confided to you that she experiences
cramping abdominal pains and diarrheic episodes upon
ingestion of milk and dairy products. She expressed her
curiosity regarding lactose intolerance and requested
information regarding this condition. All of the
following are inappropriate health teaching, aside from:
ANSWER: “It’s a condition associated with
insufficient lactase, a digestive enzyme.”
Lactose intolerance is a condition associated with
insufficient or absent lactase, a disaccharidase needed to
transform lactose into galactose and glucose.
The lack of lactase means the intestines cannot absorb
lactose which results in the typical symptoms of LI:
diarrhea, abdominal pain, distention, flatulence, nausea
etc.
Milk with a lower fat content has a higher concentration
of lactose. It is not an allergic reaction (milk allergy is a
completely separate condition).
95. You have noted that client with a history of
cardiovascular diseases was advised to increase his
intake of soluble fiber. This dietary modification, in this
case, is necessary because:
ANSWER: Soluble fiber has been proven to decrease
serum cholesterol levels.
Soluble fiber is known to decrease serum LDL and
cholesterol levels, helpful in clients with CVDs.
Choices B and D are health benefits from ingesting
insoluble fiber, not soluble.
Choice C, although partly true, is not the top priority as
the situation did not state that the client has a weight
problem.
96. Nurse Arya is conducting a nutritional
assessment of Lito, a child who is an inhabitant of a rural
village which had been hit with drought and famine.
Which of the following assessment findings would most
likely lead Nurse Arya to suspect that the Lito has
kwashiorkor?
ANSWER: Presence of a pot belly
The main symptom of kwashiorkor is extensive edema
hence a child suffering from this condition would have a
puffy appearance and abdominal edema (Choice B).
Choices A, C and D are all more commonly associated
with marasmus and not kwashiorkor.
97. Mr. Snorlax is a 38-year old client who wants to
institute dietary and lifestyle changes in order to
decrease his chances of having a cardiac-related event in
the future. All of the following must be included in your
health teaching, aside from:
ANSWER: “A low HDL level means you are
reducing your chances of having heart disease.”
98. While conducting a health class on the benefits of
eating food with unsaturated fat instead of saturated, you
would know that further teaching is unnecessary if the
client states:
ANSWER: “I should stop using coconut oil when
cooking.”
Coconut oil, palm oil and chocolate, although coming
from plant sources, contain substantially more saturated
fat than unsaturated.
Choice B is wrong because fish, especially fatty fish,
contain Omega-3 fatty acid, a type of polyunsaturated fat
that is helpful in decreasing the chances for heart
disease.
Choice D is also incorrect. Hydrogenation is process that
turns unsaturated fat into saturated fat; hence
hydrogenated margarine is very high in saturated fat.
99. Mio is a 28-year old married woman who wants
to use topical retinoic acid (Avita) to decrease the fine
wrinkles on her face, and asks you about what she
should know about this medication. Which of the
following would be a suitable answer?
ANSWER: “We have to ascertain first that you are
not pregnant.”
ODB: NURSING FACTS AND BELIEFS NURSING
THERAPEUTIC 1
Nursing Care/Positioning AFTER the procedure:
1. Thoracentesis- Unaffected side
2. Lobectomy- Unaffected side, with chest tube
3. Segmentectomy- Unaffected side, with chest tube
4. Pneumonectomy- Affected side (slightly affected 5. Suspected Appendicits- Avoid applying heat,
side) No complete lateral turning to prev. giving laxative, Enema
mediastinal shift), No chest tube 6. Post spinal cord injury- Avoid flexion of the neck
5. Eye surgery- Unoperated side down (unaffected 7. Increased ICP/IOP- Avoid coughing, vomiting,
side) Valsalva
6. Liver biopsy- Right side CHARACTERISTIC SIGNS/SYMPTOMS AND
7. Lumbar puncture- Flat on bed DISORDERS
8. Lower spinal surgery- Flat on bed, log rolling Meniere’s Disease- Vertigo, tinnitus and hearing
(turning technique) loss
9. Cervical spinal surgery- Slight elevation of head Retinal detachment- Flashes, floaters and veils
10. Cardiac catheterization- Bed rest X 24 hours, Glaucoma- Increased IOP, loss of peripheral
affected extremity in Extension, sand bag over site, vision, tunnel vision and Halos, rainbows around
assess peripheral pulses lights
11. Hip replacement- Affected limb Abducted Cataract- Opacity of the lens, painless loss of
12. Amputation- Elevate extremity for 24 hours vision
13. Supratentorial surgery- Semi-Fowler’s position Parkinson’s disease- Bradykinesia, cogwheel
14. Infratentorial surgery- Flat position, avoid neck rigidity, shuffling propulsive gait and Pill rolling
flexion tremor
Nursing care/positioning DURING the procedure: Guillain Barre syndrome- Ascending paralysis
1. Paracentesis- Sitting position Myasthenia Graves- Ptosis, dysphagia, respiratory
2. Thoracentesis- Upright leaning on overbed table, paralysis
sitting Straddling a chair Multiple Sclerosis- Charcot’s Triad (scanning
3. Insertion of TPN catheter- Trendelenburg position speech, intention tremors, nystagmus)
4. Enema Adult- left lateral position Infant/small Poliomyelitis- Flaccid paralysis
children- dorsal recumbent Fracture- Crepitus
5. TURP- Lithotomy position, cystoclysis Abdominal aortic aneurysm- Pulsating abdominal
6. Female Catheterization- Dorsal recumbent mass
Important Nursing Care BEFORE THE Gouty arthritis- Tophi
PROCEDURE Rheumatoid arthritis- Subcutaneous nodules,
1. Paracentesis- Empty bladder, weigh patient morning stiffness
2. Bowel surgery/colonoscopy- Cleansing Enema Osteoarthritis- Heberdens nodules, Bouchard
3. Liver Biopsy- Administer Vitamin K to prevent nodules
bleeding Acromegaly- Coarse facial features, wide hands
4. CT Scan with dye/IVP- Assess allergy and feet
5. MRI- Asses for claustrophobia. Remove metals Cretinism- Physical and mental retardation
6. Ultrasound of KUB-P- Full Bladder Graves disease- Exopthalmos, tachycardia, heat
7. Ultrasound of LGBP- NPO FMN, Laxative HS intolerance
8. ABG- determination Allen’s Test Syndrome of inappropriate antidiuretic
9. Giving Digitalis- Assess Apical Pulse (5th L ICS hormone secretion (SIADH)- Water intoxication,
MCL) hyponatremia
10. Giving Narcotics- Assess RR Diabetes insipidus- Polyuria, decreased specific
POSITIONING FOR gravity of urine
1. Arterial disorders- Put leg on dependent position Diabetes mellitus- Polyphagia, polyuria,
2. Venous disorders- Elevate extremity polydipsia, hyperglycemia
3. Increased ICP- Head elevated 15 to 30 degrees & Diabetic ketoacidosis (DKA)- Kussmaull
Avoid neck flexion respiration, ketonemia, ketonuria, fruity odor in
4. COPD- Upright position breath
Pheochromocytoma- Marked hypertension
NURSING ALERTS!
Increased ICP- Cushing’s Sign (increased systolic
1. Post Hip Replacement- Avoid Hip BP. Bradycardia, decreased RR) Altered LOC, wide
Flexion/adduction pulse pressure
2. Pulsating abdominal mass- Avoid abdominal Meningitis- Kernig’s sign, Brudzinski sign, nuchal
palpation rigidity
3. Glaucoma- Avoid Mydriatics (Atropine) Hypocalcemia- Chvostek’s sign, Trousseau’s sign,
4. DVT. Thrombophlebitis- Avoid massaging legs tetany, cramps
vigorously
Pancreatitis- Cullen’s sign
Deep vein thrombosis, thrombophlebitis-
Homans sign
Cholecystitis- Right upper quadrant pain, nausea
and vomiting, fat intolerance
Glomerulonephritis- Periorbital edema, increased
ASO titer
AIDS- Kaposis’ sarcoma, Pneumocystiiis carinii
pneumonia infection
Addison’s disease- Bronze skin pigmentation,
hypotension
Alzheimer’s disease- Progressive memory loss
Pernicious anemia- Beefy red tongue, lack of
intrinsic factor
Angina Pectoris- Chest pain relieved by rest and
nitroglycerin
Appendicitis- Right lower quadrant pain, rebound
tenderness, + Blumberg sign + Psoas sign
Paralytic ileus- Boardlike abdomen/abdominal
rigidity, absent bowel sounds
Ascites- Abdominal distension, + fluid wave
Laryngeal Cancer- Persistent hoarseness
Bronchogenic Cancer- Chronic cough, hemoptysis
Cancer- Anorexia, weight loss, cachexia
Colorectal Cancer lower GI bleeding
-Hematochezia
Upper GI bleeding- Melena
Emphysema- Pink puffer, barrel shaped chest
Chronic Bronchitis- Blue bloater
Asthma- Wheezes, mucoid cough, allergic reaction
Pneumococcal pneumonia- Rusty sputum
Pulmonary Tuberculosis- Night sweat,
hemoptysis, (+) mantoux test
Systemic lupus erythematosus (SLE)- Butterfly
rash
Hodgkin’s disease- Painless cervical lymph node
enlargement
Breast Cancer- Orange peel appearance, dimpling,
retraction of nipple
Bell’s Palsy- Paralysis of one side of face
Benign prostatic hyperplasia (BPH)- Decreased
urinary stream, nocturia
Arterial disorder (ASO, TAO)- Intermittent
claudication
2nd degree burn- Epidermal and dermal
involvement with blister/vesicles
Gastric Cancer- Dyspepsia, early satiety
Cardiac tamponade Hypotension- muffled heart
sounds
Right side heart failure- Jugular vein distension,
ascites, pitting dependent edema
Left side heart failure- pulmonary edema
Crackles/rales, PND, increased PAP, Increased
PCWP
Cerebrovascular accident (CVA)-
Hemiplegia/hemiparesis, aphasia, homonymous
hemianopsia
Scoliosis- Lateral curvature of spine
Pott’s disease- Gibbus formation
Flail chest- Paradoxical chest movement, dyspnea
Diverticulitis- Left lower quadrant pain
Biliary obstruction- Jaundice, icteric sclerae,
acholic stool, tea-colored urine output
Hepatic encephalopathy- Altered LOC, Flapping
tremor (asterixis)
Hiatal hernia- Heartburn
Polycythemia Vera- Reddish-purple hue of skin
and mucosa
Carbon monoxide poisoning- Cherry red skin
Valvular heart disease- Murmur
Peripheral Vascular Occlusion- Bruit
Pericarditis Pericardial- friction rub
Pleuritis- Pleural friction rub
Trigeminal Neuralgia- Severe shooting pain in one
side of the face
Ulcerative colitis- Bloody mucoid diarrhea
ODB: NURSING FACTS AND BELIEFS
NURSING THERAPEUTIC 2
Hypothalamus controls body’s temperature
Temperature is the balance between heat
production and heat losses
Factors that affect temperature are BMR, Age,
thyroxine output, Hormones, time, stress
Alteration in temperature includes pyrexia
(38.1C above),hyperpyrexia (41C) and
hypothermia (35 C below)
Tympanic temperature reading best reflect core
temperature
Pulse is control by the Autonomic Nervous
System
Factors that affect pulse rate are age, gender,
position,medication, stress
Apical pulse should be assess on a lying position
Carotid pulse is assessed for cardiac arrest for
adult and brachial pulse for infant and child.
Defibrillation kills the heart temporarily
Respiration is controlled by Medulla oblongata
and Pons
Factors that affect respiration are age,
environment, altitude, stress, medication
Blood pressure is determined by blood volume,
elasticity of the blood vessels, hematocrit level
and peripheral resistance
Orthostatic Blood pressure measurement is used
to monitor the drop of blood pressure.
Physical assessment is used to confirm, validate
and refuse a data
Cephalocaudal approach is used when doing
physical assessment
The four modes of physical assessment are
Inspection, palpation, percussion and
auscultation
Consent must be obtained for physical
assessment
Privacy should be observed in conducting
physical assessment
Thermotherapy increased superficial
temperature and local metabolic rate,
Heat therapy is contraindicated for acute muscle
injury, impaired circulation, sensory
impairment, bruises and open wound
In most hospital, the water temperature is
controlled at a temperature not to exceed 43.3 C
to prevent injury
Petroleum jelly may be used to prevent tissue
damage when hot packs are applied
Monitor Vital sign frequently when systemic
cold is applied
When using hypothermia blanket, use towel to
wrap hands and feet to protect skin from injury
Observe skin for purplish color, and check client
for numb feeling after cold application are
removed
Do not allow the client to lie on a “constant heat
source” such as heating pad or aquathermic pad
Do not apply heat to an edematous area until the
reason for edema has been determined
Gel packs provide more aggressive cooling than
ice bags, so deserve grater caution
During cold therapy, erythema will occur
The four stages of cold progression are cold,
stinging,
burning, numbness
Discontinue cold therapy upon numbness
Never apply a fully cooled cold packs directly to
the skin
Bony areas usually requires half the treatment
time as fatty areas
Do not apply an instant chemical pack to the
face and never use pins to secure pack
Elderly clients are more susceptible to injury
from heat and cold therapy as a result of
physiologic changes or medical conditions
Vital signs and frequent assessment may need to
be carried out during heat and cold therapy as
vasodilation from heat or vasoconstriction from
cold can cause changes in cardiac function and
blood pressure
Pressure sore is caused by three basic factors:
pressure, friction, shearing force
Factors that might be at risk in developing a
pressure sore are: malnutrition, increased
temperature, decreased protein intake, decreased
sensation, decreased mental capacity,
immobility
Pressure ulcer are graded from stage 1 to 4
The three major phases of wound healing are
inflammation, proliferation and maturation
The RYB (red, yellow, black) classifies open
wounds that are healing by secondary or delayed
primary intention in both acute and chronic
wound
The three types of wound healing are primary,
secondary and tertiary intention
The goals of wound healing includes: remove
necrotic tissue, prevent infection, absorb
drainage, maintain a moist environment, protect
wound from further injury
Ensure that skin is kept clean and prevent it
from getting too dry
Provide a balanced diet high in protein, vitamins
and mineral for tissue repair
Ensure a fluid intake of 2,000 mL/day for
adequate hydration
Do not elevate head of the bed more than 30
degrees
Reposition a bedridden client at least every 2
hours and achair bound client every hour
Common fecal elimination problem includes
constipation, diarrhea, incontinence, flatulence
Lack of exercise, irregular defecation habits,
bland diet and overuse of laxative are all thought
to contribute to constipation
Sufficient fluid and fiber intake are required to
keep feces soft
An adverse effect of constipation is straining
during defecation
An adverse effect of prolonged diarrhea is fluid
and electrolyte imbalances
When inspecting the client stool, the nurse must
observe its color, consistency, shape, amount,
odor, and the constituents
Digital removal of an impaction should be
carried out gently
Enema is used to relieve constipation, fecal
impaction, flatulence and is also used for
evacuation and in lowering body temperature
Proper positioning must be observed in doing
enema. Left lateral position for adults and dorsal
recumbent position for child and infants
Urinary elimination depends on normal
functioning of the urinary, cardiovascular and
nervous system
Alteration in urine production and elimination
includes polyuria, oliguria, anuria, frequency,
nocturia, urgency, enuresis, hematuria,
incontinence and retention
Incontinence can be physically and emotionally
distressing to client
Clients with urinary retention is at risk for tract
infection
The most common cause of urinary tract
infection is invasive procedure
Goals for client with problems with urinary
elimination problems includes maintaining or
restoring normal elimination patterns and
preventing skin breakdown
Urinary catheterization is frequently required for
clients with urinary retention but is only
performed when all other measures to facilitate
voiding fails
Gradual decompression should be done in doing
straight catheterization
Fr 16 – 18 is used from male client and Fr 12 –
14 is used for female client for catheterization
For retention catheter, inflate the balloon with 5
ml of sterile NSS
For client with retention catheter, acidifying
urine is a must. Food such as meat, fish, eggs
and cereals
Normal pH of urine is 6 or a range of 4.6 – 8
Clean voided specimen is used for routine
urinalysis
Midstream urine specimen is used for urine
culture
Timed urine specimen collection is used to
assess the ability of the kidney to concentrate
and dilute urine; determine level of specific
constituents; determine disorders of glucose
metabolism
If the client or staff forgets and discard the
client’s urine during times collection, the
procedure must be restarted from the beginning
To collect a stool specimen for infant, the stool
is scraped from the diaper
For occult blood examination, the client should
be instructed to avoid dark-colored food, red
meat, iron andn hemoglobin rich food for 48 –
74 hours
Avoid collecting specimen during menstrual
period
Sputum specimen is best collected early
morning to help the client expectorate all the
secretions that has been accumulated at night
Method of sputum collection includes deep
breathing and coughing exercise, suctioning and
chest physiotherapy
Blood test are the most commonly used
diagnostic test and can provide valuable
information about the hematologic system and
other body system
Walker promotes more stability compare to cane
and crutches
Crutches observes different gaits such as: 4
point gait, 3 point gait and 2 point gait, plus
swing to and swing through
Cane should always be places on the stronger
side of the body
Client should always be free from restraint
Reason for placing the client on a restraint
includes: disruptive behavior, procedure and
transfer
Never anchor the restraint on the side rail
Free movement should be provided when
placing the client on a restraint
Two types of visualization are direct and
indirect. Direct methods make use of gadget or
instrument to visualize a body area/organ.
Indirect methods make use of dye, electrical
impulses
KUB X-ray (kidney, ureters, bladders) are
painless
For voiding cystourethrogram films are taken
before, during and after voiding
Retrograde pyelogram (RPG) outlines the pelvis
and ureters. Epinephrine at the bedside should
be prepared
A pink tinged urine is normal after cystoscopy
because of the irritation of the mucus membrane
Distending bladder for KUB ultrasound is done
for better imaging
A 24 hours bed rest after renal biopsy is
encouraged to prevent bleeding
Blood Transfusion is used to improve the
oxygen carrying capacity of the blood and
restore the blood volume
0.9% NaCl is the only fluid solution allowed for
blood transfusion
Label the blood and warm the blood at a room
temperature
Use needle gauge 18 or 19 for BT to allow easy
flow of the blood
Do not mix medication with blood transfusion
Stop the transfusion immediately for any
complication that might occur during blood
transfusion
Fundamentals of Nursing Notes 1
1. A blood pressure cuff that’s too narrow can
cause a falsely elevated blood pressure reading.
2. When preparing a single injection for a patient
who takes regular and neutral protein Hagedorn insulin,
the nurse should draw the regular insulin into the syringe
first so that it does not contaminate the regular insulin.
3. Rhonchi are the rumbling sounds heard on lung
auscultation. They are more pronounced during
expiration than during inspiration.
4. Gavage is forced feeding, usually through a
gastric tube (a tube passed into the stomach through the
mouth).
5. According to Maslow’s hierarchy of needs,
physiologic needs (air, water, food, shelter, sex, activity,
and comfort) have the highest priority.
6. The safest and surest way to verify a patient’s
identity is to check the identification band on his wrist.
7. In the therapeutic environment, the patient’s
safety is the primary concern.
8. Fluid oscillation in the tubing of a chest drainage
system indicates that the system is working properly.
9. The nurse should place a patient who has a
Sengstaken-Blakemore tube in semi-Fowler position.
10. The nurse can elicit Trousseau’s sign by
occluding the brachial or radial artery. Hand and finger
spasms that occur during occlusion indicate Trousseau’s
sign and suggest hypocalcemia.
11. For blood transfusion in an adult, the appropriate
needle size is 16 to 20G.
12. Intractable pain is pain that incapacitates a
patient and can’t be relieved by drugs.
13. In an emergency, consent for treatment can be
obtained by fax, telephone, or other telegraphic means.
14. Decibel is the unit of measurement of sound.
15. Informed consent is required for any invasive
procedure.
16. A patient who can’t write his name to give
consent for treatment must make an X in the presence of
two witnesses, such as a nurse, priest, or physician.
17. The Z-track I.M. injection technique seals the
drug deep into the muscle, thereby minimizing skin
irritation and staining. It requires a needle that’s 1″ (2.5
cm) or longer.
18. In the event of fire, the acronym most often used
is RACE. (R) Remove the patient. (A) Activate the
alarm. (C) Attempt to contain the fire by closing the
door. (E) Extinguish the fire if it can be done safely.
19. A registered nurse should assign a licensed
vocational nurse or licensed practical nurse to perform
bedside care, such as suctioning and drug administration.
20. If a patient can’t void, the first nursing action
should be bladder palpation to assess for bladder
distention.
21. The patient who uses a cane should carry it on
the unaffected side and advance it at the same time as
the affected extremity.
22. To fit a supine patient for crutches, the nurse
should measure from the axilla to the sole and add 2″ (5
cm) to that measurement.
23. Assessment begins with the nurse’s first
encounter with the patient and continues throughout the
patient’s stay. The nurse obtains assessment data through
the health history, physical examination, and review of
diagnostic studies.
24. The appropriate needle size for insulin injection
is 25G and 5/8″ long.
25. Residual urine is urine that remains in the
bladder after voiding. The amount of residual urine is
normally 50 to 100 ml.
26. The five stages of the nursing process are
assessment, nursing diagnosis, planning,
implementation, and evaluation.
27. Assessment is the stage of the nursing process in
which the nurse continuously collects data to identify a
patient’s actual and potential health needs.
28. Nursing diagnosis is the stage of the nursing
process in which the nurse makes a clinical judgment
about individual, family, or community responses to
actual or potential health problems or life processes.
29. Planning is the stage of the nursing process in
which the nurse assigns priorities to nursing diagnoses,
defines short-term and long-term goals and expected
outcomes, and establishes the nursing care plan.
30. Implementation is the stage of the nursing
process in which the nurse puts the nursing care plan
into action, delegates specific nursing interventions to
members of the nursing team, and charts patient
responses to nursing interventions.
31. Evaluation is the stage of the nursing process in
which the nurse compares objective and subjective data
with the outcome criteria and, if needed, modifies the
nursing care plan.
32. Before administering any “as needed” pain
medication, the nurse should ask the patient to indicate
the location of the pain.
33. Jehovah’s Witnesses believe that they shouldn’t
receive blood components donated by other people.
34. To test visual acuity, the nurse should ask the
patient to cover each eye separately and to read the eye
chart with glasses and without, as appropriate.
35. When providing oral care for an unconscious
patient, to minimize the risk of aspiration, the nurse
should position the patient on the side.
36. During assessment of distance vision, the patient
should stand 20′ (6.1 m) from the chart.
37. For a geriatric patient or one who is extremely
ill, the ideal room temperature is 66° to 76° F (18.8° to
24.4° C).
38. Normal room humidity is 30% to 60%.
39. Hand washing is the single best method of
limiting the spread of microorganisms. Once gloves are
removed after routine contact with a patient, hands
should be washed for 10 to 15 seconds.
40. To perform catheterization, the nurse should
place a woman in the dorsal recumbent position.
41. A positive Homan’s sign may indicate
thrombophlebitis.
42. Electrolytes in a solution are measured in
milliequivalents per liter (mEq/L). A milliequivalent is
the number of milligrams per 100 milliliters of a
solution.
43. Metabolism occurs in two phases: anabolism
(the constructive phase) and catabolism (the destructive
phase).
44. The basal metabolic rate is the amount of energy
needed to maintain essential body functions. It’s
measured when the patient is awake and resting, hasn’t
eaten for 14 to 18 hours, and is in a comfortable, warm
environment.
45. The basal metabolic rate is expressed in calories
consumed per hour per kilogram of body weight.
46. Dietary fiber (roughage), which is derived from
cellulose, supplies bulk, maintains intestinal motility,
and helps to establish regular bowel habits.
47. Alcohol is metabolized primarily in the liver.
Smaller amounts are metabolized by the kidneys and
lungs.
48. Petechiae are tiny, round, purplish red spots that
appear on the skin and mucous membranes as a result of
intradermal or submucosal hemorrhage.
49. Purpura is a purple discoloration of the skin
that’s caused by blood extravasation.
50. According to the standard precautions
recommended by the Centers for Disease Control and
Prevention, the nurse shouldn’t recap needles after use.
Most needle sticks result from missed needle recapping.
51. The nurse administers a drug by I.V. push by
using a needle and syringe to deliver the dose directly
into a vein, I.V. tubing, or a catheter.
52. When changing the ties on a tracheostomy tube,
the nurse should leave the old ties in place until the new
ones are applied.
53. A nurse should have assistance when changing
the ties on a tracheostomy tube.
54. A filter is always used for blood transfusions.
55. A four-point (quad) cane is indicated when a
patient needs more stability than a regular cane can
provide.
56. A good way to begin a patient interview is to
ask, “What made you seek medical help?”
57. When caring for any patient, the nurse should
follow standard precautions for handling blood and body
fluids.
58. Potassium (K+) is the most abundant cation in
intracellular fluid.
59. In the four-point, or alternating, gait, the patient
first moves the right crutch followed by the left foot and
then the left crutch followed by the right foot.
60. In the three-point gait, the patient moves two
crutches and the affected leg simultaneously and then
moves the unaffected leg.
61. In the two-point gait, the patient moves the right
leg and the left crutch simultaneously and then moves
the left leg and the right crutch simultaneously.
62. The vitamin B complex, the water-soluble
vitamins that are essential for metabolism, include
thiamine (B1), riboflavin (B2), niacin (B3), pyridoxine
(B6), and cyanocobalamin (B12).
63. When being weighed, an adult patient should be
lightly dressed and shoeless.
64. Before taking an adult’s temperature orally, the
nurse should ensure that the patient hasn’t smoked or
consumed hot or cold substances in the previous 15
minutes.
65. The nurse shouldn’t take an adult’s temperature
rectally if the patient has a cardiac disorder, anal lesions,
or bleeding hemorrhoids or has recently undergone
rectal surgery.
66. In a patient who has a cardiac disorder,
measuring temperature rectally may stimulate a vagal
response and lead to vasodilation and decreased cardiac
output.
67. When recording pulse amplitude and rhythm,
the nurse should use these descriptive measures: +3,
bounding pulse (readily palpable and forceful); +2,
normal pulse (easily palpable); +1, thready or weak
pulse (difficult to detect); and 0, absent pulse (not
detectable).
68. The intraoperative period begins when a patient
is transferred to the operating room bed and ends when
the patient is admitted to the postanesthesia care unit.
69. On the morning of surgery, the nurse should
ensure that the informed consent form has been signed;
that the patient hasn’t taken anything by mouth since
midnight, has taken a shower with antimicrobial soap,
has had mouth care (without swallowing the water), has
removed common jewelry, and has received
preoperative medication as prescribed; and that vital
signs have been taken and recorded. Artificial limbs and
other prostheses are usually removed.
70. Comfort measures, such as positioning the
patient, rubbing the patient’s back, and providing a
restful environment, may decrease the patient’s need for
analgesics or may enhance their effectiveness.
71. A drug has three names: generic name, which is
used in official publications; trade, or brand, name (such
as Tylenol), which is selected by the drug company; and
chemical name, which describes the drug’s chemical
composition.
72. To avoid staining the teeth, the patient should
take a liquid iron preparation through a straw.
73. The nurse should use the Z-track method to
administer an I.M. injection of iron dextran (Imferon).
74. An organism may enter the body through the
nose, mouth, rectum, urinary or reproductive tract, or
skin.
75. In descending order, the levels of consciousness
are alertness, lethargy, stupor, light coma, and deep
coma.
76. To turn a patient by logrolling, the nurse folds
the patient’s arms across the chest; extends the patient’s
legs and inserts a pillow between them, if needed; places
a draw sheet under the patient; and turns the patient by
slowly and gently pulling on the draw sheet.
77. The diaphragm of the stethoscope is used to hear
high-pitched sounds, such as breath sounds.
78. A slight difference in blood pressure (5 to 10
mm Hg) between the right and the left arms is normal.
79. The nurse should place the blood pressure cuff
1″ (2.5 cm) above the antecubital fossa.
80. When instilling ophthalmic ointments, the nurse
should waste the first bead of ointment and then apply
the ointment from the inner canthus to the outer canthus.
81. The nurse should use a leg cuff to measure
blood pressure in an obese patient.
82. If a blood pressure cuff is applied too loosely,
the reading will be falsely lowered.
83. Ptosis is drooping of the eyelid.
84. A tilt table is useful for a patient with a spinal
cord injury, orthostatic hypotension, or brain damage
because it can move the patient gradually from a
horizontal to a vertical (upright) position.
85. To perform venipuncture with the least injury to
the vessel, the nurse should turn the bevel upward when
the vessel’s lumen is larger than the needle and turn it
downward when the lumen is only slightly larger than
the needle.
86. To move a patient to the edge of the bed for
transfer, the nurse should follow these steps: Move the
patient’s head and shoulders toward the edge of the bed.
Move the patient’s feet and legs to the edge of the bed
(crescent position). Place both arms well under the
patient’s hips, and straighten the back while moving the
patient toward the edge of the bed.
87. When being measured for crutches, a patient
should wear shoes.
88. The nurse should attach a restraint to the part of
the bed frame that moves with the head, not to the
mattress or side rails.
89. The mist in a mist tent should never become so
dense that it obscures clear visualization of the patient’s
respiratory pattern.
90. To administer heparin subcutaneously, the nurse
should follow these steps: Clean, but don’t rub, the site
with alcohol. Stretch the skin taut or pick up a well-
defined skin fold. Hold the shaft of the needle in a dart
position. Insert the needle into the skin at a right (90-
degree) angle. Firmly depress the plunger, but don’t
aspirate. Leave the needle in place for 10 seconds.
Withdraw the needle gently at the angle of insertion.
Apply pressure to the injection site with an alcohol pad.
91. For a sigmoidoscopy, the nurse should place the
patient in the knee-chest position or Sims’ position,
depending on the physician’s preference.
92. Maslow’s hierarchy of needs must be met in the
following order: physiologic (oxygen, food, water, sex,
rest, and comfort), safety and security, love and
belonging, self-esteem and recognition, and self-
actualization.
93. When caring for a patient who has a nasogastric
tube, the nurse should apply a water-soluble lubricant to
the nostril to prevent soreness.
94. During gastric lavage, a nasogastric tube is
inserted, the stomach is flushed, and ingested substances
are removed through the tube.
95. In documenting drainage on a surgical dressing,
the nurse should include the size, color, and consistency
of the drainage (for example, “10 mm of brown mucoid
drainage noted on dressing”).
96. To elicit Babinski’s reflex, the nurse strokes the
sole of the patient’s foot with a moderately sharp object,
such as a thumbnail.
97. A positive Babinski’s reflex is shown by
dorsiflexion of the great toe and fanning out of the other
toes.
98. When assessing a patient for bladder distention,
the nurse should check the contour of the lower
abdomen for a rounded mass above the symphysis pubis.
99. The best way to prevent pressure ulcers is to
reposition the bedridden patient at least every 2 hours.
100. Antiembolism stockings decompress the
superficial blood vessels, reducing the risk of thrombus
formation.
101. In adults, the most convenient veins for
venipuncture are the basilic and median cubital veins in
the antecubital space.
102. Two to three hours before beginning a tube
feeding, the nurse should aspirate the patient’s stomach
contents to verify that gastric emptying is adequate.
103. People with type O blood are considered
universal donors.
104. People with type AB blood are considered
universal recipients.
105. Hertz (Hz) is the unit of measurement of sound
frequency.
106. Hearing protection is required when the sound
intensity exceeds 84 dB. Double hearing protection is
required if it exceeds 104 dB.
107. Prothrombin, a clotting factor, is produced in the
liver.
108. If a patient is menstruating when a urine sample
is collected, the nurse should note this on the laboratory
request.
109. During lumbar puncture, the nurse must note the
initial intracranial pressure and the color of the
cerebrospinal fluid.
110. If a patient can’t cough to provide a sputum
sample for culture, a heated aerosol treatment can be
used to help to obtain a sample.
111. If eye ointment and eyedrops must be instilled in
the same eye, the eyedrops should be instilled first.
112. When leaving an isolation room, the nurse
should remove her gloves before her mask because
fewer pathogens are on the mask.
113. Skeletal traction, which is applied to a bone with
wire pins or tongs, is the most effective means of
traction.
114. The total parenteral nutrition solution should be
stored in a refrigerator and removed 30 to 60 minutes
before use. Delivery of a chilled solution can cause pain,
hypothermia, venous spasm, and venous constriction.
115. Drugs aren’t routinely injected intramuscularly
into edematous tissue because they may not be absorbed.
116. When caring for a comatose patient, the nurse
should explain each action to the patient in a normal
voice.
117. Dentures should be cleaned in a sink that’s lined
with a washcloth.
118. A patient should void within 8 hours after
surgery.
119. An EEG identifies normal and abnormal brain
waves.
120. Samples of feces for ova and parasite tests
should be delivered to the laboratory without delay and
without refrigeration.
121. The autonomic nervous system regulates the
cardiovascular and respiratory systems.
122. When providing tracheostomy care, the nurse
should insert the catheter gently into the tracheostomy
tube. When withdrawing the catheter, the nurse should
apply intermittent suction for no more than 15 seconds
and use a slight twisting motion.
123. A low-residue diet includes such foods as
roasted chicken, rice, and pasta.
124. A rectal tube shouldn’t be inserted for longer
than 20 minutes because it can irritate the rectal mucosa
and cause loss of sphincter control.
125. A patient’s bed bath should proceed in this
order: face, neck, arms, hands, chest, abdomen, back,
legs, perineum.
126. To prevent injury when lifting and moving a
patient, the nurse should primarily use the upper leg
muscles.
127. Patient preparation for cholecystography
includes ingestion of a contrast medium and a low-fat
evening meal.
128. While an occupied bed is being changed, the
patient should be covered with a bath blanket to promote
warmth and prevent exposure.
129. Anticipatory grief is mourning that occurs for an
extended time when the patient realizes that death is
inevitable.
130. The following foods can alter the color of the
feces: beets (red), cocoa (dark red or brown), licorice
(black), spinach (green), and meat protein (dark brown).
131. When preparing for a skull X-ray, the patient
should remove all jewelry and dentures.
132. The fight-or-flight response is a sympathetic
nervous system response.
133. Bronchovesicular breath sounds in peripheral
lung fields are abnormal and suggest pneumonia.
134. Wheezing is an abnormal, high-pitched breath
sound that’s accentuated on expiration.
135. Wax or a foreign body in the ear should be
flushed out gently by irrigation with warm saline
solution.
136. If a patient complains that his hearing aid is “not
working,” the nurse should check the switch first to see
if it’s turned on and then check the batteries.
137. The nurse should grade hyperactive biceps and
triceps reflexes as +4.
138. If two eye medications are prescribed for twice-
daily instillation, they should be administered 5 minutes
apart.
139. In a postoperative patient, forcing fluids helps
prevent constipation.
140. A nurse must provide care in accordance with
standards of care established by the American Nurses
Association, state regulations, and facility policy.
141. The kilocalorie (kcal) is a unit of energy
measurement that represents the amount of heat needed
to raise the temperature of 1 kilogram of water 1° C.
142. As nutrients move through the body, they
undergo ingestion, digestion, absorption, transport, cell
metabolism, and excretion.
143. The body metabolizes alcohol at a fixed rate,
regardless of serum concentration.
144. In an alcoholic beverage, proof reflects the
percentage of alcohol multiplied by 2. For example, a
100-proof beverage contains 50% alcohol.
145. A living will is a witnessed document that states
a patient’s desire for certain types of care and treatment.
These decisions are based on the patient’s wishes and
views on quality of life.
146. The nurse should flush a peripheral heparin lock
every 8 hours (if it wasn’t used during the previous 8
hours) and as needed with normal saline solution to
maintain patency.
147. Quality assurance is a method of determining
whether nursing actions and practices meet established
standards.
148. The five rights of medication administration are
the right patient, right drug, right dose, right route of
administration, and right time.
149. The evaluation phase of the nursing process is to
determine whether nursing interventions have enabled
the patient to meet the desired goals.
150. Outside of the hospital setting, only the
sublingual and translingual forms of nitroglycerin should
be used to relieve acute anginal attacks.
151. The implementation phase of the nursing
process involves recording the patient’s response to the
nursing plan, putting the nursing plan into action,
delegating specific nursing interventions, and
coordinating the patient’s activities.
152. The Patient’s Bill of Rights offers patients
guidance and protection by stating the responsibilities of
the hospital and its staff toward patients and their
families during hospitalization.
153. To minimize omission and distortion of facts,
the nurse should record information as soon as it’s
gathered.
154. When assessing a patient’s health history, the
nurse should record the current illness chronologically,
beginning with the onset of the problem and continuing
to the present.
155. When assessing a patient’s health history, the
nurse should record the current illness chronologically,
beginning with the onset of the problem and continuing
to the present.
156. A nurse shouldn’t give false assurance to a
patient.
157. After receiving preoperative medication, a
patient isn’t competent to sign an informed consent
form.
158. When lifting a patient, a nurse uses the weight of
her body instead of the strength in her arms.
159. A nurse may clarify a physician’s explanation
about an operation or a procedure to a patient, but must
refer questions about informed consent to the physician.
160. When obtaining a health history from an acutely
ill or agitated patient, the nurse should limit questions to
those that provide necessary information.
161. If a chest drainage system line is broken or
interrupted, the nurse should clamp the tube
immediately.
162. The nurse shouldn’t use her thumb to take a
patient’s pulse rate because the thumb has a pulse that
may be confused with the patient’s pulse.
163. An inspiration and an expiration count as one
respiration.
164. Eupnea is normal respiration.
165. During blood pressure measurement, the patient
should rest the arm against a surface. Using muscle
strength to hold up the arm may raise the blood pressure.
166. Major, unalterable risk factors for coronary
artery disease include heredity, sex, race, and age.
167. Inspection is the most frequently used
assessment technique.
168. Family members of an elderly person in a long-
term care facility should transfer some personal items
(such as photographs, a favorite chair, and knickknacks)
to the person’s room to provide a comfortable
atmosphere.
169. Pulsus alternans is a regular pulse rhythm with
alternating weak and strong beats. It occurs in
ventricular enlargement because the stroke volume
varies with each heartbeat.
170. The upper respiratory tract warms and
humidifies inspired air and plays a role in taste, smell,
and mastication.
171. Signs of accessory muscle use include shoulder
elevation, intercostal muscle retraction, and scalene and
sternocleidomastoid muscle use during respiration.
172. When patients use axillary crutches, their palms
should bear the brunt of the weight.
173. Activities of daily living include eating, bathing,
dressing, grooming, toileting, and interacting socially.
174. Normal gait has two phases: the stance phase, in
which the patient’s foot rests on the ground, and the
swing phase, in which the patient’s foot moves forward.
175. The phases of mitosis are prophase, metaphase,
anaphase, and telophase.
176. The nurse should follow standard precautions in
the routine care of all patients.
177. The nurse should use the bell of the stethoscope
to listen for venous hums and cardiac murmurs.
178. The nurse can assess a patient’s general
knowledge by asking questions such as “Who is the
president of the United States?”
179. Cold packs are applied for the first 20 to 48
hours after an injury; then heat is applied. During cold
application, the pack is applied for 20 minutes and then
removed for 10 to 15 minutes to prevent reflex dilation
(rebound phenomenon) and frostbite injury.
180. The pons is located above the medulla and
consists of white matter (sensory and motor tracts) and
gray matter (reflex centers).
181. The autonomic nervous system controls the
smooth muscles.
182. A correctly written patient goal expresses the
desired patient behavior, criteria for measurement, time
frame for achievement, and conditions under which the
behavior will occur. It’s developed in collaboration with
the patient.
183. Percussion causes five basic notes: tympany
(loud intensity, as heard over a gastric air bubble or
puffed out cheek), hyperresonance (very loud, as heard
over an emphysematous lung), resonance (loud, as heard
over a normal lung), dullness (medium intensity, as
heard over the liver or other solid organ), and flatness
(soft, as heard over the thigh).
184. The optic disk is yellowish pink and circular,
with a distinct border.
185. A primary disability is caused by a pathologic
process. A secondary disability is caused by inactivity.
186. Nurses are commonly held liable for failing to
keep an accurate count of sponges and other devices
during surgery.
187. The best dietary sources of vitamin B6 are liver,
kidney, pork, soybeans, corn, and whole-grain cereals.
188. Iron-rich foods, such as organ meats, nuts,
legumes, dried fruit, green leafy vegetables, eggs, and
whole grains, commonly have a low water content.
189. Collaboration is joint communication and
decision making between nurses and physicians. It’s
designed to meet patients’ needs by integrating the care
regimens of both professions into one comprehensive
approach.
190. Bradycardia is a heart rate of fewer than 60
beats/minute.
191. A nursing diagnosis is a statement of a patient’s
actual or potential health problem that can be resolved,
diminished, or otherwise changed by nursing
interventions.
192. During the assessment phase of the nursing
process, the nurse collects and analyzes three types of
data: health history, physical examination, and
laboratory and diagnostic test data.
193. The patient’s health history consists primarily of
subjective data, information that’s supplied by the
patient.
194. The physical examination includes objective
data obtained by inspection, palpation, percussion, and
auscultation.
195. When documenting patient care, the nurse
should write legibly, use only standard abbreviations,
and sign each entry. The nurse should never destroy or
attempt to obliterate documentation or leave vacant
lines.
196. Factors that affect body temperature include
time of day, age, physical activity, phase of menstrual
cycle, and pregnancy.
197. The most accessible and commonly used artery
for measuring a patient’s pulse rate is the radial artery.
To take the pulse rate, the artery is compressed against
the radius.
198. In a resting adult, the normal pulse rate is 60 to
100 beats/minute. The rate is slightly faster in women
than in men and much faster in children than in adults.
199. Laboratory test results are an objective form of
assessment data.
200. The measurement systems most commonly used
in clinical practice are the metric system, apothecaries’
system, and household system.
201. Before signing an informed consent form, the
patient should know whether other treatment options are
available and should understand what will occur during
the preoperative, intraoperative, and postoperative
phases; the risks involved; and the possible
complications. The patient should also have a general
idea of the time required from surgery to recovery. In
addition, he should have an opportunity to ask questions.
202. A patient must sign a separate informed consent
form for each procedure.
203. During percussion, the nurse uses quick, sharp
tapping of the fingers or hands against body surfaces to
produce sounds. This procedure is done to determine the
size, shape, position, and density of underlying organs
and tissues; elicit tenderness; or assess reflexes.
204. Ballottement is a form of light palpation
involving gentle, repetitive bouncing of tissues against
the hand and feeling their rebound.
205. A foot cradle keeps bed linen off the patient’s
feet to prevent skin irritation and breakdown, especially
in a patient who has peripheral vascular disease or
neuropathy.
206. Gastric lavage is flushing of the stomach and
removal of ingested substances through a nasogastric
tube. It’s used to treat poisoning or drug overdose.
207. During the evaluation step of the nursing
process, the nurse assesses the patient’s response to
therapy.
208. Bruits commonly indicate life- or limb-
threatening vascular disease.
209. O.U. means each eye. O.D. is the right eye, and
O.S. is the left eye.
210. To remove a patient’s artificial eye, the nurse
depresses the lower lid.
211. The nurse should use a warm saline solution to
clean an artificial eye.
212. A thready pulse is very fine and scarcely
perceptible.
213. Axillary temperature is usually 1° F lower than
oral temperature.
214. After suctioning a tracheostomy tube, the nurse
must document the color, amount, consistency, and odor
of secretions.
215. On a drug prescription, the abbreviation p.c.
means that the drug should be administered after meals.
216. After bladder irrigation, the nurse should
document the amount, color, and clarity of the urine and
the presence of clots or sediment.
217. After bladder irrigation, the nurse should
document the amount, color, and clarity of the urine and
the presence of clots or sediment.
218. Laws regarding patient self-determination vary
from state to state. Therefore, the nurse must be familiar
with the laws of the state in which she works.
219. Gauge is the inside diameter of a needle: the
smaller the gauge, the larger the diameter.
220. An adult normally has 32 permanent teeth.
Fundamentals of Nursing Notes 2
1. After turning a patient, the nurse should document the
position used, the time that the patient was turned, and
the findings of skin assessment.
2. PERRLA is an abbreviation for normal pupil
assessment findings: pupils equal, round, and reactive to
light with accommodation.
3. When percussing a patient’s chest for postural
drainage, the nurse’s hands should be cupped.
4. When measuring a patient’s pulse, the nurse should
assess its rate, rhythm, quality, and strength.
5. Before transferring a patient from a bed to a
wheelchair, the nurse should push the wheelchair
footrests to the sides and lock its wheels.
6. When assessing respirations, the nurse should
document their rate, rhythm, depth, and quality.
7. For a subcutaneous injection, the nurse should use a
5/8″ to 1″ 25G needle.
8. The notation “AA & O × 3” indicates that the patient
is awake, alert, and oriented to person (knows who he
is), place (knows where he is), and time (knows the date
and time).
9. Fluid intake includes all fluids taken by mouth,
including foods that are liquid at room temperature, such
as gelatin, custard, and ice cream; I.V. fluids; and fluids
administered in feeding tubes. Fluid output includes
urine, vomitus, and drainage (such as from a nasogastric
tube or from a wound) as well as blood loss, diarrhea or
feces, and perspiration.
10. After administering an intradermal injection, the
nurse shouldn’t massage the area because massage can
irritate the site and interfere with results.
11. When administering an intradermal injection, the
nurse should hold the syringe almost flat against the
patient’s skin (at about a 15-degree angle), with the
bevel up.
12. To obtain an accurate blood pressure, the nurse
should inflate the manometer to 20 to 30 mm Hg above
the disappearance of the radial pulse before releasing the
cuff pressure.
13. The nurse should count an irregular pulse for 1 full
minute.
14. A patient who is vomiting while lying down should
be placed in a lateral position to prevent aspiration of
vomitus.
15. Prophylaxis is disease prevention.
16. Body alignment is achieved when body parts are in
proper relation to their natural position.
17. Trust is the foundation of a nurse-patient
relationship.
18. Blood pressure is the force exerted by the circulating
volume of blood on the arterial walls.
19. Malpractice is a professional’s wrongful conduct,
improper discharge of duties, or failure to meet
standards of care that causes harm to another.
20. As a general rule, nurses can’t refuse a patient care
assignment; however, in most states, they may refuse to
participate in abortions.
21. A nurse can be found negligent if a patient is injured
because the nurse failed to perform a duty that a
reasonable and prudent person would perform or
because the nurse performed an act that a reasonable and
prudent person wouldn’t perform.
22. States have enacted Good Samaritan laws to
encourage professionals to provide medical assistance at
the scene of an accident without fear of a lawsuit arising
from the assistance. These laws don’t apply to care
provided in a health care facility.
23. A physician should sign verbal and telephone orders
within the time established by facility policy, usually 24
hours.
24. A competent adult has the right to refuse lifesaving
medical treatment; however, the individual should be
fully informed of the consequences of his refusal.
25. Although a patient’s health record, or chart, is the
health care facility’s physical property, its contents
belong to the patient.
26. Before a patient’s health record can be released to a
third party, the patient or the patient’s legal guardian
must give written consent.
27. Under the Controlled Substances Act, every dose of
a controlled drug that’s dispensed by the pharmacy must
be accounted for, whether the dose was administered to a
patient or discarded accidentally.
28. A nurse can’t perform duties that violate a rule or
regulation established by a state licensing board, even if
they are authorized by a health care facility or physician.
29. To minimize interruptions during a patient interview,
the nurse should select a private room, preferably one
with a door that can be closed.
30. In categorizing nursing diagnoses, the nurse
addresses life-threatening problems first, followed by
potentially life-threatening concerns.
31. The major components of a nursing care plan are
outcome criteria (patient goals) and nursing
interventions.
32. Standing orders, or protocols, establish guidelines for
treating a specific disease or set of symptoms.
33. In assessing a patient’s heart, the nurse normally
finds the point of maximal impulse at the fifth intercostal
space, near the apex.
34. The S1 heard on auscultation is caused by closure of
the mitral and tricuspid valves.
35. To maintain package sterility, the nurse should open
a wrapper’s top flap away from the body, open each side
flap by touching only the outer part of the wrapper, and
open the final flap by grasping the turned-down corner
and pulling it toward the body.
36. The nurse shouldn’t dry a patient’s ear canal or
remove wax with a cotton-tipped applicator because it
may force cerumen against the tympanic membrane.
37. A patient’s identification bracelet should remain in
place until the patient has been discharged from the
health care facility and has left the premises.
38. The Controlled Substances Act designated five
categories, or schedules, that classify controlled drugs
according to their abuse potential.
39. Schedule I drugs, such as heroin, have a high abuse
potential and have no currently accepted medical use in
the United States.
40. Schedule II drugs, such as morphine, opium, and
meperidine (Demerol), have a high abuse potential, but
currently have accepted medical uses. Their use may
lead to physical or psychological dependence.
41. Schedule III drugs, such as paregoric and
butabarbital (Butisol), have a lower abuse potential than
Schedule I or II drugs. Abuse of Schedule III drugs may
lead to moderate or low physical or psychological
dependence, or both.
42. Schedule IV drugs, such as chloral hydrate, have a
low abuse potential compared with Schedule III drugs.
43. Schedule V drugs, such as cough syrups that contain
codeine, have the lowest abuse potential of the
controlled substances.
44. Activities of daily living are actions that the patient
must perform every day to provide self-care and to
interact with society.
45. Testing of the six cardinal fields of gaze evaluates
the function of all extraocular muscles and cranial nerves
III, IV, and VI.
46. The six types of heart murmurs are graded from 1 to
6. A grade 6 heart murmur can be heard with the
stethoscope slightly raised from the chest.
47. The most important goal to include in a care plan is
the patient’s goal.
48. Fruits are high in fiber and low in protein, and
should be omitted from a low-residue diet.
49. The nurse should use an objective scale to assess and
quantify pain. Postoperative pain varies greatly among
individuals.
50. Postmortem care includes cleaning and preparing the
deceased patient for family viewing, arranging
transportation to the morgue or funeral home, and
determining the disposition of belongings.
51. The nurse should provide honest answers to the
patient’s questions.
52. Milk shouldn’t be included in a clear liquid diet.
53. When caring for an infant, a child, or a confused
patient, consistency in nursing personnel is paramount.
54. The hypothalamus secretes vasopressin and
oxytocin, which are stored in the pituitary gland.
55. The three membranes that enclose the brain and
spinal cord are the dura mater, pia mater, and arachnoid.
56. A nasogastric tube is used to remove fluid and gas
from the small intestine preoperatively or
postoperatively.
57. Psychologists, physical therapists, and chiropractors
aren’t authorized to write prescriptions for drugs.
58. The area around a stoma is cleaned with mild soap
and water.
59. Vegetables have a high fiber content.
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60. The nurse should use a tuberculin syringe to
administer a subcutaneous injection of less than 1 ml.
61. For adults, subcutaneous injections require a 25G
5/8″ to 1″ needle; for infants, children, elderly, or very
thin patients, they require a 25G to 27G ½” needle.
62. Before administering a drug, the nurse should
identify the patient by checking the identification band
and asking the patient to state his name.
63. To clean the skin before an injection, the nurse uses
a sterile alcohol swab to wipe from the center of the site
outward in a circular motion.
64. The nurse should inject heparin deep into
subcutaneous tissue at a 90-degree angle (perpendicular
to the skin) to prevent skin irritation.
65. If blood is aspirated into the syringe before an I.M.
injection, the nurse should withdraw the needle, prepare
another syringe, and repeat the procedure.
66. The nurse shouldn’t cut the patient’s hair without
written consent from the patient or an appropriate
relative.
67. If bleeding occurs after an injection, the nurse should
apply pressure until the bleeding stops. If bruising
occurs, the nurse should monitor the site for an enlarging
hematoma.
68. When providing hair and scalp care, the nurse should
begin combing at the end of the hair and work toward
the head.
69. The frequency of patient hair care depends on the
length and texture of the hair, the duration of
hospitalization, and the patient’s condition.
70. Proper function of a hearing aid requires careful
handling during insertion and removal, regular cleaning
of the ear piece to prevent wax buildup, and prompt
replacement of dead batteries.
71. The hearing aid that’s marked with a blue dot is for
the left ear; the one with a red dot is for the right ear.
72. A hearing aid shouldn’t be exposed to heat or
humidity and shouldn’t be immersed in water.
73. The nurse should instruct the patient to avoid using
hair spray while wearing a hearing aid.
74. The five branches of pharmacology are
pharmacokinetics, pharmacodynamics,
pharmacotherapeutics, toxicology, and pharmacognosy.
75. The nurse should remove heel protectors every 8
hours to inspect the foot for signs of skin breakdown.
76. Heat is applied to promote vasodilation, which
reduces pain caused by inflammation.
77. A sutured surgical incision is an example of healing
by first intention (healing directly, without granulation).
78. Healing by secondary intention (healing by
granulation) is closure of the wound when granulation
tissue fills the defect and allows reepithelialization to
occur, beginning at the wound edges and continuing to
the center, until the entire wound is covered.
79. Keloid formation is an abnormality in healing that’s
characterized by overgrowth of scar tissue at the wound
site.
80. The nurse should administer procaine penicillin by
deep I.M. injection in the upper outer portion of the
buttocks in the adult or in the midlateral thigh in the
child. The nurse shouldn’t massage the injection site.
81. An ascending colostomy drains fluid feces. A
descending colostomy drains solid fecal matter.
82. A folded towel (scrotal bridge) can provide scrotal
support for the patient with scrotal edema caused by
vasectomy, epididymitis, or orchitis.
83. When giving an injection to a patient who has a
bleeding disorder, the nurse should use a small-gauge
needle and apply pressure to the site for 5 minutes after
the injection.
84. Platelets are the smallest and most fragile formed
element of the blood and are essential for coagulation.
85. To insert a nasogastric tube, the nurse instructs the
patient to tilt the head back slightly and then inserts the
tube. When the nurse feels the tube curving at the
pharynx, the nurse should tell the patient to tilt the head
forward to close the trachea and open the esophagus by
swallowing. (Sips of water can facilitate this action.)
86. Families with loved ones in intensive care units
report that their four most important needs are to have
their questions answered honestly, to be assured that the
best possible care is being provided, to know the
patient’s prognosis, and to feel that there is hope of
recovery.
87. Double-bind communication occurs when the verbal
message contradicts the nonverbal message and the
receiver is unsure of which message to respond to.
88. A nonjudgmental attitude displayed by a nurse
shows that she neither approves nor disapproves of the
patient.
89. Target symptoms are those that the patient finds
most distressing.
90. A patient should be advised to take aspirin on an
empty stomach, with a full glass of water, and should
avoid acidic foods such as coffee, citrus fruits, and cola.
91. For every patient problem, there is a nursing
diagnosis; for every nursing diagnosis, there is a goal;
and for every goal, there are interventions designed to
make the goal a reality. The keys to answering
examination questions correctly are identifying the
problem presented, formulating a goal for the problem,
and selecting the intervention from the choices provided
that will enable the patient to reach that goal.
92. Fidelity means loyalty and can be shown as a
commitment to the profession of nursing and to the
patient.
93. Administering an I.M. injection against the patient’s
will and without legal authority is battery.
94. An example of a third-party payer is an insurance
company.
95. The formula for calculating the drops per minute for
an I.V. infusion is as follows: (volume to be infused ×
drip factor) ÷ time in minutes = drops/minute
96. On-call medication should be given within 5 minutes
of the call.
97. Usually, the best method to determine a patient’s
cultural or spiritual needs is to ask him.
98. An incident report or unusual occurrence report isn’t
part of a patient’s record, but is an in-house document
that’s used for the purpose of correcting the problem.
99. Critical pathways are a multidisciplinary guideline
for patient care.
100. When prioritizing nursing diagnoses, the following
hierarchy should be used: Problems associated with the
airway, those concerning breathing, and those related to
circulation.
101. The two nursing diagnoses that have the highest
priority that the nurse can assign are Ineffective airway
clearance and Ineffective breathing pattern.
102. A subjective sign that a sitz bath has been effective
is the patient’s expression of decreased pain or
discomfort.
103. For the nursing diagnosis Deficient diversional
activity to be valid, the patient must state that he’s
“bored,” that he has “nothing to do,” or words to that
effect.
104. The most appropriate nursing diagnosis for an
individual who doesn’t speak English is Impaired verbal
communication related to inability to speak dominant
language (English).
105. The family of a patient who has been diagnosed as
hearing impaired should be instructed to face the
individual when they speak to him.
106. Before instilling medication into the ear of a patient
who is up to age 3, the nurse should pull the pinna down
and back to straighten the eustachian tube.
107. To prevent injury to the cornea when administering
eyedrops, the nurse should waste the first drop and instill
the drug in the lower conjunctival sac.
108. After administering eye ointment, the nurse should
twist the medication tube to detach the ointment.
109. When the nurse removes gloves and a mask, she
should remove the gloves first. They are soiled and are
likely to contain pathogens.
110. Crutches should be placed 6″ (15.2 cm) in front of
the patient and 6″ to the side to form a tripod
arrangement.
111. Listening is the most effective communication
technique.
112. Before teaching any procedure to a patient, the
nurse must assess the patient’s current knowledge and
willingness to learn.
113. Process recording is a method of evaluating one’s
communication effectiveness.
114. When feeding an elderly patient, the nurse should
limit high-carbohydrate foods because of the risk of
glucose intolerance.
115. When feeding an elderly patient, essential foods
should be given first.
116. Passive range of motion maintains joint mobility.
Resistive exercises increase muscle mass.
117. Isometric exercises are performed on an extremity
that’s in a cast.
118. A back rub is an example of the gate-control theory
of pain.
119. Anything that’s located below the waist is
considered unsterile; a sterile field becomes unsterile
when it comes in contact with any unsterile item; a
sterile field must be monitored continuously; and a
border of 1″ (2.5 cm) around a sterile field is considered
unsterile.
120. A “shift to the left” is evident when the number of
immature cells (bands) in the blood increases to fight an
infection.
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121. A “shift to the right” is evident when the number of
mature cells in the blood increases, as seen in advanced
liver disease and pernicious anemia.
122. Before administering preoperative medication, the
nurse should ensure that an informed consent form has
been signed and attached to the patient’s record.
123. A nurse should spend no more than 30 minutes per
8-hour shift providing care to a patient who has a
radiation implant.
124. A nurse shouldn’t be assigned to care for more than
one patient who has a radiation implant.
125. Long-handled forceps and a lead-lined container
should be available in the room of a patient who has a
radiation implant.
126. Usually, patients who have the same infection and
are in strict isolation can share a room.
127. Diseases that require strict isolation include
chickenpox, diphtheria, and viral hemorrhagic fevers
such as Marburg disease.
128. For the patient who abides by Jewish custom, milk
and meat shouldn’t be served at the same meal.
129. Whether the patient can perform a procedure
(psychomotor domain of learning) is a better indicator of
the effectiveness of patient teaching than whether the
patient can simply state the steps involved in the
procedure (cognitive domain of learning).
130. According to Erik Erikson, developmental stages
are trust versus mistrust (birth to 18 months), autonomy
versus shame and doubt (18 months to age 3), initiative
versus guilt (ages 3 to 5), industry versus inferiority
(ages 5 to 12), identity versus identity diffusion (ages 12
to 18), intimacy versus isolation (ages 18 to 25),
generativity versus stagnation (ages 25 to 60), and ego
integrity versus despair (older than age 60).
131. When communicating with a hearing impaired
patient, the nurse should face him.
132. An appropriate nursing intervention for the spouse
of a patient who has a serious incapacitating disease is to
help him to mobilize a support system.
133. Hyperpyrexia is extreme elevation in temperature
above 106° F (41.1° C).
134. Milk is high in sodium and low in iron.
135. When a patient expresses concern about a health-
related issue, before addressing the concern, the nurse
should assess the patient’s level of knowledge.
136. The most effective way to reduce a fever is to
administer an antipyretic, which lowers the temperature
set point.
137. When a patient is ill, it’s essential for the members
of his family to maintain communication about his
health needs.
138. Ethnocentrism is the universal belief that one’s way
of life is superior to others.
139. When a nurse is communicating with a patient
through an interpreter, the nurse should speak to the
patient and the interpreter.
140. In accordance with the “hot-cold” system used by
some Mexicans, Puerto Ricans, and other Hispanic and
Latino groups, most foods, beverages, herbs, and drugs
are described as “cold.”
141. Prejudice is a hostile attitude toward individuals of
a particular group.
142. Discrimination is preferential treatment of
individuals of a particular group. It’s usually discussed
in a negative sense.
143. Increased gastric motility interferes with the
absorption of oral drugs.
144. The three phases of the therapeutic relationship are
orientation, working, and termination.
145. Patients often exhibit resistive and challenging
behaviors in the orientation phase of the therapeutic
relationship.
146. Abdominal assessment is performed in the
following order: inspection, auscultation, percussion &
palpation.
147. When measuring blood pressure in a neonate, the
nurse should select a cuff that’s no less than one-half and
no more than two-thirds the length of the extremity
that’s used.
148. When administering a drug by Z-track, the nurse
shouldn’t use the same needle that was used to draw the
drug into the syringe because doing so could stain the
skin.
149. Sites for intradermal injection include the inner
arm, the upper chest, and on the back, under the scapula.
150. When evaluating whether an answer on an
examination is correct, the nurse should consider
whether the action that’s described promotes autonomy
(independence), safety, self-esteem, and a sense of
belonging.
151. When answering a question on the NCLEX
examination, the student should consider the cue (the
stimulus for a thought) and the inference (the thought) to
determine whether the inference is correct. When in
doubt, the nurse should select an answer that indicates
the need for further information to eliminate ambiguity.
For example, the patient complains of chest pain (the
stimulus for the thought) and the nurse infers that the
patient is having cardiac pain (the thought). In this case,
the nurse hasn’t confirmed whether the pain is cardiac. It
would be more appropriate to make further assessments.
152. Veracity is truth and is an essential component of a
therapeutic relationship between a health care provider
and his patient.
153. Beneficence is the duty to do no harm and the duty
to do good. There’s an obligation in patient care to do no
harm and an equal obligation to assist the patient.
154. Nonmaleficence is the duty to do no harm.
155. Frye’s ABCDE cascade provides a framework for
prioritizing care by identifying the most important
treatment concerns.
156. A = Airway. This category includes everything that
affects a patent airway, including a foreign object, fluid
from an upper respiratory infection, and edema from
trauma or an allergic reaction.
157. B = Breathing. This category includes everything
that affects the breathing pattern, including
hyperventilation or hypoventilation and abnormal
breathing patterns, such as Korsakoff’s, Biot’s, or
Cheyne-Stokes respiration.
158. C = Circulation. This category includes everything
that affects the circulation, including fluid and
electrolyte disturbances and disease processes that affect
cardiac output.
159. D = Disease processes. If the patient has no
problem with the airway, breathing, or circulation, then
the nurse should evaluate the disease processes, giving
priority to the disease process that poses the greatest
immediate risk. For example, if a patient has terminal
cancer and hypoglycemia, hypoglycemia is a more
immediate concern.
160. E = Everything else. This category includes such
issues as writing an incident report and completing the
patient chart. When evaluating needs, this category is
never the highest priority.
161. When answering a question on an NCLEX
examination, the basic rule is “assess before action.” The
student should evaluate each possible answer carefully.
Usually, several answers reflect the implementation
phase of nursing and one or two reflect the assessment
phase. In this case, the best choice is an assessment
response unless a specific course of action is clearly
indicated.
162. Rule utilitarianism is known as the “greatest good
for the greatest number of people” theory.
163. Egalitarian theory emphasizes that equal access to
goods and services must be provided to the less fortunate
by an affluent society.
164. Active euthanasia is actively helping a person to
die.
165. Brain death is irreversible cessation of all brain
function.
166. Passive euthanasia is stopping the therapy that’s
sustaining life.
167. A third-party payer is an insurance company.
168. Utilization review is performed to determine
whether the care provided to a patient was appropriate
and cost-effective.
169. A value cohort is a group of people who
experienced an out-of-the-ordinary event that shaped
their values.
170. Voluntary euthanasia is actively helping a patient to
die at the patient’s request.
171. Bananas, citrus fruits, and potatoes are good
sources of potassium.
172. Good sources of magnesium include fish, nuts, and
grains.
173. Beef, oysters, shrimp, scallops, spinach, beets, and
greens are good sources of iron.
174. Intrathecal injection is administering a drug through
the spine.
175. When a patient asks a question or makes a
statement that’s emotionally charged, the nurse should
respond to the emotion behind the statement or question
rather than to what’s being said or asked.
176. The steps of the trajectory-nursing model are as
follows:
177. Step 1: Identifying the trajectory phase
178. Step 2: Identifying the problems and establishing
goals
179. Step 3: Establishing a plan to meet the goals
180. Step 4: Identifying factors that facilitate or hinder
attainment of the goals
181. Step 5: Implementing interventions
182. Step 6: Evaluating the effectiveness of the
interventions
183. A Hindu patient is likely to request a vegetarian
diet.
184. Pain threshold, or pain sensation, is the initial point
at which a patient feels pain.
185. The difference between acute pain and chronic pain
is its duration.
186. Referred pain is pain that’s felt at a site other than
its origin.
187. Alleviating pain by performing a back massage is
consistent with the gate control theory.
188. Romberg’s test is a test for balance or gait.
189. Pain seems more intense at night because the
patient isn’t distracted by daily activities.
190. Older patients commonly don’t report pain because
of fear of treatment, lifestyle changes, or dependency.
191. No pork or pork products are allowed in a Muslim
diet.
192. Two goals of Healthy People 2010 are:
193. Help individuals of all ages to increase the quality
of life and the number of years of optimal health
194. Eliminate health disparities among different
segments of the population.
195. A community nurse is serving as a patient’s
advocate if she tells a malnourished patient to go to a
meal program at a local park.
196. If a patient isn’t following his treatment plan, the
nurse should first ask why.
197. Falls are the leading cause of injury in elderly
people.
198. Primary prevention is true prevention. Examples
are immunizations, weight control, and smoking
cessation.
199. Secondary prevention is early detection. Examples
include purified protein derivative (PPD), breast self-
examination, testicular self-examination, and chest X-
ray.
200. Tertiary prevention is treatment to prevent long-
term complications.
201. A patient indicates that he’s coming to terms with
having a chronic disease when he says, “I’m never going
to get any better.”
202. On noticing religious artifacts and literature on a
patient’s night stand, a culturally aware nurse would ask
the patient the meaning of the items.
203. A Mexican patient may request the intervention of a
curandero, or faith healer, who involves the family in
healing the patient.
204. In an infant, the normal hemoglobin value is 12
g/dl.
205. The nitrogen balance estimates the difference
between the intake and use of protein.
206. Most of the absorption of water occurs in the large
intestine.
207. Most nutrients are absorbed in the small intestine.
208. When assessing a patient’s eating habits, the nurse
should ask, “What have you eaten in the last 24 hours?”
209. A vegan diet should include an abundant supply of
fiber.
210. A hypotonic enema softens the feces, distends the
colon, and stimulates peristalsis.
211. First-morning urine provides the best sample to
measure glucose, ketone, pH, and specific gravity
values.
212. To induce sleep, the first step is to minimize
environmental stimuli.
213. Before moving a patient, the nurse should assess
the patient’s physical abilities and ability to understand
instructions as well as the amount of strength required to
move the patient.
214. To lose 1 lb (0.5 kg) in 1 week, the patient must
decrease his weekly intake by 3,500 calories
(approximately 500 calories daily). To lose 2 lb (1 kg) in
1 week, the patient must decrease his weekly caloric
intake by 7,000 calories (approximately 1,000 calories
daily).
215. To avoid shearing force injury, a patient who is
completely immobile is lifted on a sheet.
216. To insert a catheter from the nose through the
trachea for suction, the nurse should ask the patient to
swallow.
217. Vitamin C is needed for collagen production.
218. Only the patient can describe his pain accurately.
219. Cutaneous stimulation creates the release of
endorphins that block the transmission of pain stimuli.
220. Patient-controlled analgesia is a safe method to
relieve acute pain caused by surgical incision, traumatic
injury, labor and delivery, or cancer.
221. An Asian American or European American
typically places distance between himself and others
when communicating.
222. The patient who believes in a scientific, or
biomedical, approach to health is likely to expect a drug,
treatment, or surgery to cure illness.
223. Chronic illnesses occur in very young as well as
middle-aged and very old people.
224. The trajectory framework for chronic illness states
that preferences about daily life activities affect
treatment decisions.
225. Exacerbations of chronic disease usually cause the
patient to seek treatment and may lead to hospitalization.
226. School health programs provide cost-effective
health care for low-income families and those who have
no health insurance.
227. Collegiality is the promotion of collaboration,
development, and interdependence among members of a
profession.
228. A change agent is an individual who recognizes a
need for change or is selected to make a change within
an established entity, such as a hospital.
229. The patients’ bill of rights was introduced by the
American Hospital Association.
230. Abandonment is premature termination of treatment
without the patient’s permission and without appropriate
relief of symptoms.
231. Values clarification is a process that individuals use
to prioritize their personal values.
232. Distributive justice is a principle that promotes
equal treatment for all.
233. Milk and milk products, poultry, grains, and fish
are good sources of phosphate.
234. The best way to prevent falls at night in an oriented,
but restless, elderly patient is to raise the side rails.
235. By the end of the orientation phase, the patient
should begin to trust the nurse.
236. Falls in the elderly are likely to be caused by poor
vision.
237. Barriers to communication include language
deficits, sensory deficits, cognitive impairments,
structural deficits, and paralysis.
238. The three elements that are necessary for a fire are
heat, oxygen, and combustible material.
239. Sebaceous glands lubricate the skin.
240. To check for petechiae in a dark-skinned patient,
the nurse should assess the oral mucosa.
241. To put on a sterile glove, the nurse should pick up
the first glove at the folded border and adjust the fingers
when both gloves are on.
242. To increase patient comfort, the nurse should let the
alcohol dry before giving an intramuscular injection.
243. Treatment for a stage 1 ulcer on the heels includes
heel protectors.
244. Seventh-Day Adventists are usually vegetarians.
245. Endorphins are morphine-like substances that
produce a feeling of well-being.
246. Pain tolerance is the maximum amount and
duration of pain that an individual is willing to endure.
Physical Assessment
Integument
Skin: The client’s skin is uniform in color, unblemished
and no presence of any foul odor. He has a good skin
turgor and skin’s temperature is within normal limit.
Hair: The hair of the client is thick, silky hair is evenly
distributed and has a variable amount of body hair.
There are also no signs of infection and infestation
observed.
Nails: The client has a light brown nails and has the
shape of convex curve. It is smooth and is intact with the
epidermis. When nails pressed between the fingers
(Blanch Test), the nails return to usual color in less than
4 seconds.
Head
Head: The head of the client is rounded; normocephalic
and symmetrical.
Skull: There are no nodules or masses and depressions
when palpated.
Face: The face of the client appeared smooth and has
uniform consistency and with no presence of nodules or
masses.
Eyes and Vision
Eyebrows: Hair is evenly distributed. The client’s
eyebrows are symmetrically aligned and showed equal
movement when asked to raise and lower eyebrows.
Eyelashes: Eyelashes appeared to be equally distributed
and curled slightly outward.
Eyelids: There were no presence of discharges, no
discoloration and lids close symmetrically with
involuntary blinks approximately 15-20 times per
minute.
Eyes
The Bulbar conjunctiva appeared transparent with few
capillaries evident.
The sclera appeared white.
The palpebral conjunctiva appeared shiny, smooth and
pink.
There is no edema or tearing of the lacrimal gland.
Cornea is transparent, smooth and shiny and the details
of the iris are visible. The client blinks when the cornea
was touched.
The pupils of the eyes are black and equal in size. The
iris is flat and round. PERRLA (pupils equally round
respond to light accommodation), illuminated and non-
illuminated pupils constricts. Pupils constrict when
looking at near object and dilate at far object. Pupils
converge when object is moved towards the nose.
When assessing the peripheral visual field, the client can
see objects in the periphery when looking straight ahead.
When testing for the Extraocular Muscle, both eyes of
the client coordinately moved in unison with parallel
alignment.
The client was able to read the newsprint held at a
distance of 14 inches.
Ears and Hearing
Ears: The Auricles are symmetrical and has the same
color with his facial skin. The auricles are aligned with
the outer canthus of eye. When palpating for the texture,
the auricles are mobile, firm and not tender. The pinna
recoils when folded. During the assessment of Watch
tick test, the client was able to hear ticking in both ears.
Nose and Sinus
Nose: The nose appeared symmetric, straight and
uniform in color. There was no presence of discharge or
flaring. When lightly palpated, there were no tenderness
and lesions
Mouth
The lips of the client are uniformly pink; moist,
symmetric and have a smooth texture. The client was
able to purse his lips when asked to whistle.
Teeth and Gums: There are no discoloration of the
enamels, no retraction of gums, pinkish in color of gums
The buccal mucosa of the client appeared as uniformly
pink; moist, soft, glistening and with elastic texture.
The tongue of the client is centrally positioned. It is pink
in color, moist and slightly rough. There is a presence of
thin whitish coating.
The smooth palates are light pink and smooth while the
hard palate has a more irregular texture.
The uvula of the client is positioned in the midline of the
soft palate.
Neck
The neck muscles are equal in size. The client showed
coordinated, smooth head movement with no discomfort.
The lymph nodes of the client are not palpable.
The trachea is placed in the midline of the neck.
The thyroid gland is not visible on inspection and the
glands ascend during swallowing but are not visible.
Thorax, Lungs, and Abdomen
Lungs / Chest: The chest wall is intact with no
tenderness and masses. There’s a full and symmetric
expansion and the thumbs separate 2-3 cm during deep
inspiration when assessing for the respiratory excursion.
The client manifested quiet, rhythmic and effortless
respirations.
The spine is vertically aligned. The right and left
shoulders and hips are of the same height.
Heart: There were no visible pulsations on the aortic
and pulmonic areas. There is no presence of heaves or
lifts.
Abdomen: The abdomen of the client has an
unblemished skin and is uniform in color. The abdomen
has a symmetric contour. There were symmetric
movements caused associated with client’s respiration.
The jugular veins are not visible.
When nails pressed between the fingers (Blanch Test),
the nails return to usual color in less than 4 seconds.
Extremities
The extremities are symmetrical in size and length.
Muscles: The muscles are not palpable with the absence
of tremors. They are normally firm and showed smooth,
coordinated movements.
Bones: There were no presence of bone deformities,
tenderness and swelling.
Joints: There were no swelling, tenderness and joints
move smoothly.
Performing a Comprehensive Health Assessment
A comprehensive health assessment includes:
 A complete medical history, A general survey, A
complete physical assessment
The medical history and the general survey were
previously detailed. In this section, you will review the
components of the complete physical assessment.
Vital Signs
The pulse, blood pressure, bodily temperature and
respiratory rate are measured and documented.
Assessment of the Thorax
Inspection: The anterior and posterior thorax is
inspected for size, symmetry, shape and for the presence
of any skin lesions and/or misalignment of the spine;
chest movements are observed for the normal movement
of the diaphragm during respirations.
Palpation: The posterior thorax is assessed for
respiratory excursion and fremitus.
Percussion: For normal and abnormal sounds over the
thorax
Assessment of the Lungs
Auscultation: The assessment of normal and
adventitious breath sounds.
Percussion: For normal and abnormal sounds. Normal
breath sounds like vesicular breath sounds, bronchial
breath sounds, bronchovesicular breath sounds are
auscultated and assessed in the same manner that
adventitious breath sounds like rales, wheezes, friction
rubs, rhonchi, and abnormal bronchophony, egophony,
and whispered pectoriloquy are auscultated, assessed
and documented.
Assessment of the Cardiovascular System
Inspection: Pulsations indicating the possibility of an
aortic aneurysm
Auscultation: Listening to systolic heart sounds like the
normal S1 heart sound and abnormal clicks, the diastolic
heart sounds of S2, S3, S4, diastolic knocks and mitral
valve sounds, all of which are abnormal with the
exception of S2 which can be normal among clients less
than 40 years of age.
Assessment of the Peripheral Vascular System
Inspection: The extremities are inspected for any
abnormal color and any signs of poor perfusion to the
extremities, particularly the lower extremities. While the
client is in a supine position, the nurse also assesses the
jugular veins for any bulging pulsations or distention.
Auscultation: The nurse assesses the carotids for the
presence of any abnormal bruits.
Palpation: The peripheral veins are gently touched to
determine the temperature of the skin, the presence of
any tenderness and swelling.
The peripheral vein pulses are also palpated bilaterally to
determine regularity, number of beats, volume and
bilateral equality in terms of these characteristics.
Assessment of the Musculoskeletal System
Inspection: The major muscles of the body are inspected
by the nurse to determine their size, and strength, and the
presence of any tremors, contractures, muscular
weakness and/or paralysis. All joints are assessed for
their full range of motion. The areas around the bones
and the major muscle groups are also inspected to
determine any areas of deformity, swelling and/or
tenderness.
Palpation: The muscles are palpated to determine the
presence of any spasticity, flaccidity, pain, tenderness,
and tremors.
Assessment of the Neurological System
Of all of the bodily systems that are assessed by the
registered nurse, the neurological system is perhaps the
most extensive and complex.
Some of the terms and terminology relating to the
neurological system and neurological system disorders
that you should be familiar with include those below.
Acalculia: Acalculia is the client's loss of ability to
perform relatively simple mathematical calculations like
addition and subtraction.
Agnosia: Agnosia is defined as the loss of a client's
ability to recognize and identify familiar objects using
the senses despite the fact that the senses are intact and
normally functioning. The different types of agnosia, as
based on each of the five senses, are auditory agnosia,
visual agnosia, gustatory agnosia, olfactory agnosia, and
tactile agnosia.
Agraphia: Agraphia, simply defined, is the Inability of
the client to write. Agraphia is one of the four hallmark
symptoms of Gerstmann's syndrome. The other
symptoms of Gerstmann's syndrome are acalculia, finger
agnosia, and an inability to differentiate between right
and left.
Alexia: Alexia, which is a type of receptive aphasia,
occurs when the client is unable to process, understand
and read the written word. This neurological disorder is
also referred to as word blindness and optical alexia.
Anhedonia: Anhedonia is a loss of interest in life
experiences and life itself as the result of the
neurological deficit.
Anomia: Anomia is a lack of ability of the client to
name a familiar object or item.
Anosagnosia: Anosagnosia is characterized with the
client's inability to perceive and have an awareness of an
affected body part such as a paralyzed or missing leg.
Anosagnosia is closely similar to hemineglect and
hemiattention
Anosdiaphoria: Anosdiaphoria is an indifference to
one's illness and disability
Aphasia: Aphasia includes expressive aphasia and
receptive aphasia. Expressive aphasia is characterized by
the client's inability to express their feelings and wishes
to others with the spoken word; and receptive aphasia is
the client's inability to understand the spoken words of
others.
Asomatognosi: Asomatognosia is the inability of the
client to recognize one or more of their own bodily parts.
Astereognosia: Astereognosia is the client's inability to
differentiate among different textures with their sense of
touch and also the inability of the client to identify a
familiar object, like a button, with their tactile sensation.
Asymbolia: Asymbolia is the loss of the client's inability
to respond to pain even though they have the sensory
function to feel and perceive the pain. Asymbolia is also
referred to as pain dissociation and pain asymbolia.
Autotopagnosia: Autotopagnosia is the inability of the
client to locate their own body parts, the body parts of
another person, or the body parts of a medical model.
Balint's syndrome: Balint's syndrome includes ocular
apraxia, optic ataxia and simultanagnosia, which consist
of impaired visual scanning, visusopatial ability and
attention.
Boston Diagnostic Aphasia Examination: The Boston
Diagnostic Aphasia Examination is a standardized
comprehensive assessment tool that assess and measures
the client's degree of aphasia in terms of the client's
perceptions, processing of these perceptions and
responses to these perceptions while using problem
solving and comprehension skills.
Broca's aphasia: Broca's aphasia entails the client's lack
of ability to form and express words even though the
client's level of comprehension is intact.
Color agnosia: Color agnosia reflects the client's lack of
ability to recognize and name different colors.
Conduction aphasia: Conduction aphasia is the client's
lack of ability to repeat phrases and/or write brief
dictated passages despite the fact that the client has
intact speech abilities, comprehension abilities, and the
ability to name familiar objects.
Constructional apraxia: Constructional apraxia is the
inability of the client to draw and copy simple shapes on
paper.
Dressing apraxia: Dressing apraxia occurs when the
person is not able to appropriately dress oneself because
of some neurological dysfunction.
Dysgraphaesthesia: Dysgraphaesthesia impairs the
client's ability to sense and identify a letter or number
that is tactily drawn on the client's palm.
Dysgraphia: Dysgraphia is similar to agraphia;
however, dysgraphia is difficulty in terms of writing and
agraphia is the client's complete inability to write.
Environmental agnosia: Environmental agnosia is the
lack of ability of the client to recognize familiar places,
like the US Supreme Court, by looking at a photograph
of it.
Finger agnosia: Finger agnosia occurs when the person
is not able to identify what finger is being touched by the
person performing the neurological assessment.
Geographic agnosia: Geographic agnosia is the lack of
ability of the client to recognize familiar counties, like
Canada or Mexico, when viewing a world map.
Gerstmann's Syndrome: Gerstmann's Syndrome
consists of dyscalculia or acalculia, finger agnosia, one
sided disorientation and dysgraphia or agraphia.
Hemiasomatognosia: Hemiasomatognosia is the
neurological disorder that occurs when the client does
not perceive one half of their body and they act in a
manner as if that half of the body does not even exist.
Homonymous hemianopsia: Homonymous
hemianopsia occurs when the person has neurological
blindness in the same visual field of both eyes
bilaterally.
Ideomotor apraxia: Ideomotor apraxia is a neurological
deficit that affects the client's ability to pretend doing
simple tasks of everyday living like brushing one's teeth.
Misoplegia: Misoplegia is a hatred and distaste for an
adversely affected limb.
Motor alexia: Motor alexia occurs when the client is not
able to comprehend the written word despite the fact that
the client can read it aloud.
Musical alexia: Musical alexia is a client's inability to
recognize a familiar tune like "The National Anthem" or
"Silent Night".
Movement agnosia: Movement agnosia is a
neurological deficit that is characterized with a client's
lack of ability to recognize an object's movement.
Ocular apraxia: Ocular apraxia is the neurological
deficit that occurs when the person is no longer able to
rapidly move their eyes to observe a moving object.
Optic ataxia: Optic ataxia is characterized with the
client's inability to reach for and grab an object.
Phonagnosia: Phonagnosia is the client's lack of ability
to recognize familiar voices such as those of a child or
spouse.
Prosopagnosia: Prosopagnosia is a lack of ability to
recognize familiar faces, like the face of a spouse or
child.
Simultanagnosia: Simultanagnosia is a neurological
disorder that occurs when the client is not able to
perceive and process the perception of more than object
at a time that is in the client's visual field.
Somatophrenia: Somatophrenia occurs when the client
denies the fact that their body parts are not even theirs,
but instead, these body parts belong to another.
The Two-Point Discrimination Test: This test
measures and assesses the client's ability to recognize
more than one sensory perception, such as pain and
touch, at one time.
Visual agnosia: Visual agnosia is the client's lack of
ability to recognize and attach meaning to familiar
objects.
Wechsler Memory Scale IV: Wechsler Memory Scale
IV: This measurement tool is a standardized
comprehensive method to assess verbal and visual
memory, including immediate memory, delayed
memory, auditory memory, visual memory and visual
working memory..
The neurological system is assessed with:
Inspection
Balance, gait, gross motor function, fine motor function
and coordination, sensory functioning, temperature
sensory functioning, kinesthetic sensations and tactile
sensory motor functioning, as well as all of the cranial
nerves are assessed.
Balance is assessed using the relatively simple Romberg
test. The Romberg test is the test that law enforcement
use to test people for drunkenness. Gait can be assessed
by simply observing the client as they are walking or by
coaching the person to walk heal to toe as the nurse
observes the client for their gait.
Gross motor functioning is bilaterally assessed by
having the client contract their muscles; and fine motor
coordination and functioning is observed for both the
upper and the lower extremities as the client manipulates
objects.
Sensory functioning is determined by touching various
parts of the body, bilaterally, with a pen or another blunt
item while the client has their eyes closed. The client is
prompted to report whether or not they feel the blunt
item as the nurse touches the area. Similarly, a hot and
cold object is placed on the skin on various parts of the
body to assess temperature sensory functioning. The
client will then report whether they feel heat, cold or
nothing at all.
Kinesthetic sensations are assessed to determine the
client's ability to perceive and report their bodily
positioning without the help of visual cues.
Tactile sensory functioning is assessed for the client's
ability to have stereognosis, extinction, one point
discrimination and two point discrimination. One and
two point discrimination relates to the client's ability to
feel whether or not they have gotten one or two pin
pricks that the nurse gently applies. Stereognosis is the
client's ability to feel and identify a familiar object while
their eyes are closed. For example, the nurse may place a
pen, a button or a paper clip in the client's hand to
determine whether or not the client can identify the
object without any visual cues. Extinction is the client's
ability to identify whether or not they are being touched
by the person doing the assessment with either one or
two bilateral touches. For example, the nurse may touch
both knees and then ask the client if they felt one or two
touches while the client has their eyes closed.
Reflexes
Reflexes are automatic muscular responses to a stimulus.
When reflexes are absent or otherwise altered, it can
indicate a neurological deficit even earlier than other
signs and symptoms of the neurological deficit appear.
Reflexes can be described as primitive and long term.
Primitive reflexes are normally present at the time of
birth and these reflexes normally disappear as the baby
grows older; neurological deficits are suspected when
these primitive reflexes remain beyond the point in time
when they are expected to disappear. Reflexes, other
than the primitive reflexes remain intact and active
during the entire life span, under normal conditions.
The primitive reflexes are the:
 Rooting reflex: The infant will turn their head
in the direction of the side of the face that is being
gently stroked and, then, the infant will begin a
sucking action.
 Sucking reflex: The sucking reflex is
demonstrated when the infant performs sucking
actions when anything like a nipple or a finger tip
comes in contact with the infant's mouth.
 Tonic neck reflex: The tonic neck reflex, also
referred to as the fencing reflex, is demonstrated
when the infant's body takes on the appearance of a
fencer's position when the infant's head is turned to
the right or to the left.
 Galant or truncal incurvation reflex: This
reflex is seen when the infant moves their hips
toward the direction of gentle tap on their back near
the spine when the infant is in the prone position.
 Grasp reflex: Newborns grasp fingers and other
objects that are placed in their palm. They will also
tighten their grasp as the finger or another object is
slowly removed.
 Moro or startle reflex: This reflex normally
occurs with a sudden noise such as clapping of
hands. The infant will jerk when the sound is heard.
The infant's head and legs will extend and the arms
will move upward.
 Step reflex: Newborns will perform walking
like movements when the soles of the infant's feet
touch a surface such as a floor. The reflex
disappears in about six to eight weeks of age.
 Parachute reflex: The baby extends their arms
forward as if to break a fall when a person holds the
infant and rotates their body rapidly.
The other reflexes are the:
 Pupil reflex: Pupil reflexes include pupil
dilation and pupil accommodation. The "PERLA"
mnemonic for pupil reflexes stands for Pupils
Equally Reactive to Light and Accommodation
which is a normal finding. The pupil reflexes for
their reactions to light are assessed by using a flash
light in a darkened room. Pupils will normally dilate
as the light is withdrawn and they will normally
constrict when the light is brought close to the
pupils. The pupils are assessed not only for their
reaction to light, they are also assessed in terms of
their accommodation. Normally, the pupils will
dilate when an object is moved away from the eye
and they will constrict as the object is being brought
closer to the eye.
 Plantar reflex: The plantar reflex is elicited
when the person performing this assessment strokes
the bottom of the foot and the client's toes curl
down. The Babinski sign occurs when the foot goes
into dorsiflexion and the great toe curls up; this sign
is an abnormal response to this stimulation and it
can indicate the presence of deep vein thrombosis.
 Biceps reflex: This reflex is assessed by placing 6. Abducens Nerve –Motor -This cranial nerve
the thumb on the biceps tendon while the person is innervates and controls the abduction of the eye using
in a sitting position and then tapping the thumb with the lateral rectus muscle.
the Taylor hammer. 7. Facial Nerve -Motor and Sensory -The facial nerve
 Triceps reflex: This reflex is elicited by tapping controls facial movements, some salivary glands and
the triceps tendon with the Taylor hammer above the gustatory sensations from the anterior part of the tongue.
elbow while the client has their hands on their legs 8. Acoustic Nerve –Sensory -This cranial nerve senses
when the client is in a sitting position. and transmits the sense of hearing and it also senses
 Patellar tendon reflex: This reflex, often gravity and maintains balance and equilibrium.
referred to as the knee jerk reflex, is elicited by 9. Glossopharyngeal Nerve -Motor and Sensory -This
tapping the patellar area with the Taylor hammer. nerve gives us the sense of taste from the posterior
 Calcaneal reflex: This reflex, often referred to tongue, and it also innervates the parotid glands.
as the Achilles reflex, is assessed with tapping on 10. Vagus Nerve -Motor and Sensory -The vagus nerve
the calcaneal reflex on the ankle with the Taylor controls laryngeal and pharyngeal muscles and damage
hammer. to this cranial nerve can lead to swallowing disorders. It
 Gag reflex: The gag reflex is elicited when the also controls the parasympathetic nervous system to the
back of the mouth and the posterior tongue is thoracic and abdominal organs and it controls the
stimulated with a tongue blade. resonance of the voice.
 Sneeze reflex: Sneezing occurs to rid the nasal 11. Spinal Accessory Nerve –Motor -The spinal
passages of irritants. accessory nerve, in interaction with the vagus nerve,
 Blinking reflex: This reflex is elicited when the controls the trapezius and sternocleidomastoid muscles.
eyes are touched or they are stimulated a sudden 12. Hypoglossal Nerve –Motor -The hypoglossal cranial
bright light or an irritant. nerve controls the tongue, speech and swallowing.
 Cough reflex: Coughing occurs when the
airway is stimulated.
 Yawn reflex: Yawning occurs as the result of
the body's increased need for oxygen.
All reflexes should be done bilaterally in rapid
succession so that all differences between the right and
the left reflexes can be determined and assessed. For
example, when the person who is performing these
assessments should assess the biceps reflex of the right
arm and then immediately assess the biceps reflex of the
left arm so that any differences or inequalities can be
assessed and documented.
Lastly, the nurse assesses the twelve cranial nerves.
Some of these twelve cranial nerves are only sensory or
motor nerves, and others have both sensory and motor
functions.
Name of the Cranial Nerve, Classification & Function
1. Olfactory Nerve –Sensory -This nerve transmits the
sense of smell from the olfactory foramina of the nose.
2. Optic Nerve –Sensory -This cranial nerve transmits
the sense of vision from the retina to the brain.
3. Oculomotor Nerve –Motor -The oculomotor nerve
controls eye movements, the sphincter of the pupils and
the ciliary body muscles.
4. Trochlear Nerve –Motor -This cranial nerve
innervates eye ball movement and the superior oblique
muscle of the eyes.
5. Trigeminal Nerve -Motor and Sensory -The
trigeminal nerve controls the muscles that are used for
chewing food.