Exam 4: NSG121/ NSG 121 (Latest 2024/ 2025 Update) Health Assessment | Review with Questions and Verified Answers| 100% Correct| Grade A- Herzing
Exam 4: NSG121/ NSG 121 (Latest 2024/
2025 Update) Health Assessment | Review
with Questions and Verified Answers| 100%
Correct| Grade A- Herzing
Q: T/F
When there is damage to spinal column and nerves, the brain is unable to send messages to
initiate muscle contraction at or below level of injury.
Answer:
True
Q: T/F Type 2 diabetes is a modifiable risk factor
Answer:
True
Q: Who has the highest risk for stroke when looking at cultural groups?
Answer:
African American
Q: Why is dysphasia a concern after a stroke?
Answer:
Patient is at risk for aspiration
Q: Where is Broca Area?
Answer:
Frontal Lobe
Q: What is Broca Area Responsible For?
Answer:
Responsible for written language and expressive aphasia, verbal expression
Q: How would you as a nurse communicate with a patient with injury to Broca area?
Answer:
Visually
White board
Allow patient to express thoughts
Q: Damage to Wernicke Area:
Answer:
Damage to Wernicke area will have trouble comprehending verbal and written language
Q: T/F Client with stupor describes someone who can respond to stimuli but will be slower to
respond
Answer:
False, that’s drowsy. Stupor: Patient is unresponsive and can be aroused only briefly by vigorous,
repeated stimulation.
Q: Assessment Steps for Level of Consciousness
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Purpose of Frontal Lobe CognitiveMemoryJudgmentArithmeticAbstract thinking
Parietal Lobe is Responsible For SensoryRecognitionObject Size & ShapeSpeech
Temporal Lobe is Responsible For Hearing
What is the function of the cerebellum? Balance
What is the midbrain responsible for? Sends messages to and from the brain
What does the spinal cord do as far as message transmission is concerned? Carries neuron signals from midbrain to the body
What is the brainstem responsible for? Controls essential respiratory and cardiac functions
T/F When there is damage to spinal column and nerves, the brain is unable to send messages to initiate muscle contraction at or below level of injury. True
T/F Type 2 diabetes is a modifiable risk factor True
Who has the highest risk for stroke when looking at cultural groups? African American
Why is dysphasia a concern after a stroke? Patient is at risk for aspiration
Where is Broca Area? Frontal Lobe
What is Broca Area Responsible For? Responsible for written language and expressive aphasia, verbal expression
How would you as a nurse communicate with a patient with injury to Broca area? VisuallyWhite boardAllow patient to express thoughts
Damage to Wernicke Area: Damage to Wernicke area will have trouble comprehending verbal and written language
T/F Client with stupor describes someone who can respond to stimuli but will be slower to respond False, that’s drowsy. Stupor: Patient is unresponsive and can be aroused only briefly by vigorous, repeated stimulation.
Assessment Steps for Level of Consciousness Walk inSpeak to themTouch themPain (sternal rub, pinch finger)
Routine vs. Focused Neurological Assessment Routine: assess level of consciousness, pupil response, observe gait, check checking 12 cranial nerves, evaluate muscle toneFocused: further evaluate specific abnormal finding, deep tendon reflexes, 2-point discrimination, moving fingers and toes up or down with eyes closed.
What cranial nerves assess ocular motor muscular function/movement? 346
Using a scale of 0-5 to grade muscle strength, what is a 3? Can move but not with resistance, movement with gravity
Stereognosis Definition Recognizing object in the hand such as key, coin, paperclip
Graphesthesia Definition Drawing letter or number in patient’s hand with their eyes closed and have them identify
How to assess 2 point discrimination? If patient can feel one or two points on a tweezers. If they only feel one then its impaired.
Normal Babinski in Adults Toes curl but big toe dorsal flex fan out, infant they all fan out
T/F Urgent situations include change in pupillary response, less than 50mL urine output 4 hours, new seizure True
T/F Common complications associated with hospitalized patient include the placement of chest tube False, chest tube is a common procedure, not a common complication (DVT, trauma, fall, infection)
What is included in general shift assessment? Relevant to why the patient is there, includes quick head to toeComprehensive focuses on all aspects of wellbeing
What lab value shows a woman is pregnant? HCG
T/F Nausea is normal in second trimester of pregnancy False, first trimester
When do pregnant women experience shortness of breath without exertion? First trimester
During the first trimester where does the woman usually have abdominal pain? What is the pain called? Lower abdomen Round Ligament Pain
What is linea nigra?What causes linea nigra? Hyperpigmented line between the symphysis pubis and the top of the fundus found in pregnant women. Increased melanin
What is melasma?What causes melasma? Mask of pregnancy—a blotchy hyperpigmented area on the cheeks, nose, and foreheadIncreased melanin
T/F It is important to dim lights when assessing infant to keep them calm False, you want bright lights to see everything
T/F it is important to keep noise to minimum to examine infant True
What part of blood pressure increases in elderly? Systolic increases
How do elderly peoples taste change? Decreased taste
How does elderly peoples chest expansion change? Limited Expansion
Why does systolic BP increase in elderly people? Calcification of arteriesAtherosclerosis Reduced arteriole compliance
Do elderly people usually have fluid volume excess or fluid volume deficit? Fluid DeficitDehydrated
T/F To get the medical history of elderly we should only look at the medical record False, only reason to use medical record is memory or mental issue that they aren’t able to answer. First go to primary source
What should you ask a patient to assess nutritional risk factors? 1. Do you every skip meals?2. How much sugar do you eat?3. How much salt do you eat?4. How much red meat do you consume?
T/F Ptosis requires an immediate assessment False, drooping of the eye lid is normal
T/F Normal gait for elderly people includes flexed posture, using arms for balance, and short uneven steps True
Examples of IADLs Using cell phoneShopping, TransportationTaking medications
What is a risk that decreased nutritional intake puts the patient at that is not directly related to nutrition? Skin breakdown HealingPressure ulcers
Before Head to Toe What Do You Do? Weight & Height
What comes after weight & height? Head to Toe
After Head to Toe What Do You Do? Look to see if you have covered everything
After you check if you have covered everything after head to toe- what do you do? Review everything with the patient
Cranial Nerve I OlfactoryHave patient smell while plugging one nostril at a time
Cranial Nerve II OpticSnellen Chart and Confrontation
Cranial Nerve III, IV, VI Oculomotor, Trochlear, AbducensAssess pupils for size, shape, and equality. Assess the six cardinal positions of gaze. Observe for nystagmus in one or both eyes
Cranial Nerve VII FacialTest Taste Sense & Facial Movements
Cranial Nerve VIII AcousticWhisper Test
Cranial Nerve IX GlossopharyngealTest with nerve VII for taste and nerve X for swallowing
Cranial Nerve X “VagusStick out tongue and say “”ah”” Check gage reflex”
Cranial Nerve XI Spinal Accessory Controls trapezius & sternocleidomastoidHave patient shrug shoulders
Cranial Nerve XII HypoglossalEvaluate with cranial nerve X and stick out tongue
What might be causing hypereflexia in the third trimester of a pregnancy? Preeclampsia
At what age should a child triple their birth weight? 1 year
Age group associated with autonomy vs doubt 18 months to 3 years
Age group associated with industry vs inferiority 5-12 years
In children at about age 10 the respiratory rate slows down. Why is that? Alveoli get larger which increases lung volume
What is the point of obstetrical and birth history questions? obstetrical and birth history questions are used to identify risk factors for disorders and developmental difficulties
Questions for gathering information about risk factors of lead poisoning 1. Does your child live in or regularly visit a house or childcare facility built before 1950?2. Does your child live in or regularly visit a house or childcare facility built before 1978 that is being or has recently (within the past 6 months) been renovated or remodeled?3. Does your child have a brother, sister, or playmate who has or had lead poisoning?
What position should infants sleep in? Supine
Throughout the first year of life for an infant, at what points do they have well child checkups? 3-5 days after birth1 month2 months4 months6 months9 months12 months
Components of APGAR a. Heart Rateb. Respiratory Effortc. Muscle Toned. Reflex Irritabilitye. Color
A 2 year old is upset what do you check quickly before they get really irritable? Respiratory RateBreath Sounds
Cranial Nerve V Trigeminal Touch of sharp, dull, or soft and having patient identify on each extremity