NUR 220A FINAL EXAM BLUEPRINT
Review of Systems (ROS)
Deformities of Rheumatoid Arthritis
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Caused by autoimmune
Occurs any age in life.
Pain, stiff, warm and swollen
Stiffness worse in the morning gets better in the day.
Normal response vs abnormal response to DTR (deep tendon reflexes).
Deep tendon*: tapping tendon → sensory activates sensory afferent nerve → spinal cord →
synapse with motor neuron → travel to muscle → stimulates contraction
Normally these are 1+ and 2+ and equal bilaterally.
Positive vs negative Romberg’s sign
Positive Romberg sign is loss of balance that occurs when closing the eyes. You eliminate the
advantage of orientation with the eyes, which had compensated for sensory loss. A positive
Romberg sign occurs with cerebellar ataxia (multiple sclerosis, alcohol intoxication), loss of
proprioception, and loss of vestibular function.
Carpal Tunnel SyndromeTinel test, Phalen test, etc
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In carpal tunnel syndrome percussion of the median nerve produces burning and tingling
along its distribution, which is a positive Tinel sign.
Phalen test reproduces numbness and burning in a person with carpal tunnel syndrome
Reason why the musculoskeletal system shortens in the elderly/older adult
Decrease in height more apparent in 80s and 90s, caused by shortening of vertebral column
(thinning of disks and osteoporosis*)
Priority nursing
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First level: emergent, life threatening (ABC’s plus V)
Second level: prompt intervention (mental status change, acute pain, risk to safety,
abnormal lab results, acute urinary retention)
Third level: can be addressed later (long term problems, family coping, activity)
Focused vs Problem-centered Data collection
This is for a limited or short-term problem. Here you collect a “mini” database, smaller in scope
and more targeted than the complete database. It concerns mainly one problem, one cue
complex, or one body system.
NUR 220A FINAL EXAM BLUEPRINT
Phases of the interview
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Pre-interaction: collect data from medical record
Beginning/introduction: introduce yourself and your role, ask how patient would like to
be addressed, indicate reason for interview
Working: data gathering by asking questions
Closing: are there any questions you would like to ask?
Objective data vs. subjective data
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Subjective: what the patient says, symptoms (ex: ROS, chief complaint)
Objective: what can be observed, measured of verified by another individual, signs. (ex:
vital signs, general survey, chest x-ray, weight, height, age)
Signs of right sided heart failure vs left sided heart failure
Gastric vs. Peptic vs. Duodenal ulcers
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Gastric ulcer: pain increases with meal, occurs 30-`hr after meal
Duodenal ulcer: pain relieved by meal, occurs 2-3 hours after meal, pain can awake client
at night- Duodenal ulcer typically has dull, aching, gnawing pain; does not radiate; may
be relieved by food;and may awaken the person from sleep.
Peptic ulcer disease occurs with frequent use of nonsteroidal anti-inflammatory drugs
(NSAIDs), alcohol, smoking,
Male genitourinary system i.e. hyper/hypospadias
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Hypospadias- urethral meatus is ventrally positioned
Why do we auscultate the abdomen before palpation and percussion?
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Palpation and percussion increase peristalsis and create adventitious sounds
Why would stool appear pale and clay-like?
NUR 220A FINAL EXAM BLUEPRINT
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Absent of bile pigment
What causes peptic ulcers?
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Peptic ulcer disease occurs with frequent use of nonsteroidal anti-inflammatory drugs
(NSAIDs), alcohol, smoking
What information can be obtained from deep palpation of the abdomen?
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Able to feel organs such as live and spleen
Pressure in the arteries vs vein (higher vs lower)
Pressure in arteries is a high-pressure system
What kind of pitch are bruits (low or high?) in the thyroid and carotid artery
Low-pitched sounds
Hernias
A hernia is a loop of bowel protruding through a weak spot in the abdominal muscles.”
Phobias
feeling an unreasonable, irrational fear of snakes
Cranial nerves tests when 1) patient stick tongue out, b) patient says “ahh”
CN IX
Purpose of the MMSE (mini mental state examination)
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screening tool to detect dementia and delirium and todifferentiate these from psychiatric
mental illness.
4 main headings of mental status assessment (obj + subj data): Appearance, Behavior,
Cognition, Thought process
What do we assess in Increased intercranial pressure? Think LOC, Glascow coma scale + 3
other things.
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Level of consciousness, motor function, pupillary response, and vital signs
Kinesthesia test
NUR 220A FINAL EXAM BLUEPRINT
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Test the person’s ability to perceive passive movements of the extremities.
Which disease is “pill rolling” movement associated with?
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Parkinson Disease
Unrelated word test
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This tests the person’s ability to lay down new memories.
After 5 minutes ask for the recall of the four words. To test the duration of memory, ask
for a recall at 10 minutes and at 30 minutes. The normal response for people younger
than 60 years is an accurate three- or four-word recall after a 5-, 10-, and 30-minute
delay.
Which part of the brain controls balance?
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cerebellum
RAM
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Rapid alternating movement (RAM): ask patient to pat the knees with both hands, lift up,
turn hands over, and pat the knees with the back of the hands
o Normal: equal turning and a quick rhythmic pace
o Slow, clumsy, and sloppy response occurs with cerebellar disorders
Normal bicep reflex
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Flexion
Normal- which is contraction of the biceps muscle and flexion of the forearm
Define osteoporosis
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The net effect is a gradual loss of bone density
What connects bone to bone?
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ligament
Describe the Tandem walk.
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asking the patient to walk a straight line while touching the heel of one foot to the
toe of the other with each step
Ischemic vs Hemorrhagic (CVA) stroke
NUR 220A FINAL EXAM BLUEPRINT
cells are deprived of their blood supply such as when a cerebral artery becomes occluded
(ischemic stroke) or when vascular bleeding (hemorrhagic stroke) occurs.
What does the Confrontation test assess for?
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Loss of peripheral vision
Muscle strength grading
Grade description
Assessment
% Normal
5 Full ROM against gravity,
full resistance100
4 Full ROM against gravity,
some resistance
3 Full ROM with gravity 50
Fair
100
Normal
75
Good
2 Full ROM with gravity
eliminated
2 Full ROM with gravity
eliminated (passive motion)
1 Slight contraction
50
fair
25
Poor
10
Trace
0 No contraction
0
Zero
Staging pressure ulcers
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Stage I: skin intact, skin is red and unbroken
Stage II: partial skin erosion with loss of epidermis/dermis, looks like open blister (most
painful b/c nerve endings exposed)
Stage III: ulcer extending to subcutaneous, can NOT see muscle, bone, tendon
Stage IV: exposes muscle, tendon, or bone. May show slough or eschar (dead skin)
What part of the brain controls balance?
Cerebellum
Tension headache vs migraine headache
NUR 220A FINAL EXAM BLUEPRINT
Tension
Lifetime prevalence
location
quality/severity
Onset
Associated symptoms
Migraines
Most common 50%
10% of headaches, women>men
<1% more common in men
Usually bilateral
Unilateral ~70% bifrontal or
global ~30%
Unilateral, usually behind or
around eye
Pressing/tightening
throbbing/aching. Mod-severe
intensity
Sharp, severe intensity
Gradual
Fairly rapid
abrupt
Photophobia, phonophobia, scalp
tenderness
Nausea, vomit, photophobia,
phonophobia
Unilateral autonomic symptoms,
lacrimation, rhinorrhea
What does a GCS (Glasgow coma scale) of less than 7 implies?
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Coma
Vertigo
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Cluster
Lightheadedness: presyncope, which is considered dizziness
Vertigo: type of dizziness, the feeling of spinning