Mental status assessment
Which patients, regardless of presenting symptoms, should undergo a mental status examination as part of their routine evaluation?
What is every patient
What are examples of questionnaires we can utilize to assess for alcohol abuse
What are AUDIT and CAGe questionnaires
What does IPPA stand for?
What is inspection, palpation, percussion, and auscultation
What are five routes a temperature can be taken
What is oral, rectal, tympanic, axillary, and temporal
A 23-year-old female patient presents for a routine physical exam. The healthcare provider calculates her body mass index (BMI) based on her weight of 23.5 kg/m² and height. What is the classification of this patient's BMI?
What is normal
A 25-year-old male presents with disorganized speech, frequent paranoid thoughts, and auditory hallucinations. He reports using cannabis regularly since he was 16, and his mother has a history of a similar mental health disorder. What mental health disorder might you expect
What is schizophrenia
Which substance is known to interact with medications, worsen existing diseases, and increase the risk of health problems, mortality, and ICU admissions.
What is alcohol
A 45-year-old patient presents with localized redness and swelling in the right forearm. Which part of the hand should the nurse use to palpate for temperature
What is the dorsum of the hand
A 60-year-old male patient with a history of hypertension presents for a routine check-up. During the physical exam, the nurse palpates the patient's radial pulse and notes a 2+ rating. What is the term used to describe the force of this patient's pulse?
What is easily palpable
A 35-year-old woman comes to the clinic for a routine check-up. During the assessment, the nurse asks her, "Do you feel safe at home?" The patient hesitates but responds that she feels uneasy at times due to ongoing stress at home. What type of data does the healthcare provider gather by asking this question?
What is subjective data
What is a specific plan in the next 24-48 hours
A 28-year-old male is brought to the emergency department after being found unresponsive at a party. His friends report he took an unknown pill earlier in the evening. On examination, the patient has pinpoint pupils, a respiratory rate of 8 breaths per minute, and reduced responsiveness to painful stimuli. What class of substances is most likely responsible for the patient’s symptoms?
What is a CNS depressant
What sound should the nurse hear upon percussing adult lungs
What is resonance
This is the term for the highest pressure in the arteries during the heartbeat cycle, occurring when the heart's ventricles contract and pump blood also known as systole
What is systolic blood pressure
Between what age do the head and chestCircumference of an child typically even out?
What is between 6 months and 2 years
A 72-year-old man is brought in by his family due to concerns about his memory, particularly forgetting recent events and appointments. He has no history of psychiatric illness but is starting to struggle with daily tasks. You need a more detailed cognitive screening to assess his mental status. Which exam would you preform?
What is the Mini-Mental State Examination (MMSE)
This is the only type of withdrawal that can be fatal if left untreated, often requiring medical supervision to prevent complications such as seizures or delirium tremens.
What is alcohol withdrawl
A 60-year-old patient presents with complaints of shortness of breath and fatigue. The healthcare provider suspects a heart murmur and decides to auscultate the heart. To best hear the low-pitched sounds of the murmur which side of the stethoscope should the nurse use to auscultate
What is the bell
A 68-year-old woman with a history of hypertension presents to the clinic with complaints of dizziness when standing up. The nurse checks her blood pressure in both the sitting and standing positions.What results would indicate orthostatic hypotension in this patient
What is a drop in SBP of greater 20 mmHg or drop in DBP of greater than 10 mmHg with position change
A 50-year-old woman presents to the clinic with a complaint of persistent lower back pain that has lasted for over six months. The pain is described as dull and aching, with occasional sharp episodes, and has been affecting her daily activities, including walking and lifting. She has tried over-the-counter pain relievers, but the pain persists. What type of pain is this patient most likely experiencing?
What is chronic pain
A 2-year-old child is brought to the clinic by their parent, who is concerned about the child’s development. The parent mentions that the child is not speaking in two-word sentences and struggles with stacking blocks. What screening test would you use?
What is the Denver II screening test
A 24-year-old woman is brought to the clinic by her friend, who is concerned about her recent behavior. During the exam, the patient appears jittery, with dilated pupils, a rapid heart rate, and elevated blood pressure. She admits to recent drug use at a party, describing a short-term elevation in mood, alertness, energy levels, and concentration. What is the most likely cause of the patient’s symptoms?
What is CNS stimulates
An adolescent presents for a routine check-up. During the physical exam, the healthcare provider listens to the lungs and hears booming, low-pitched sounds, which are normal in this patient's age group. What is the term used to describe these normal lung sounds?
What is hyperresonance
A 45-year-old female with no known history of hypertension visits the clinic for a routine check-up. Her blood pressure is measured at 155/90 mmHg. The nurse notices that the cuff seems too tight around the patient’s arm. After adjusting the cuff and rechecking the blood pressure, the reading drops to 130/80 mmHg. What could the tight cuff have caused in the initial blood pressure measurement?
What is a false high
A 6-month-old infant is brought to the emergency department with a high fever and discomfort following a vaccination. The nurse observes the baby crying and visibly distressed, but is unable to communicate directly with the child to assess the severity of the pain. The provider decides to use a pain scale designed for young children who cannot verbalize their pain. What pain assessment tool is most appropriate for evaluating this infant's pain?
What is the FLACC scale