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Nursing Fundamentals 3

Instructions:

Answer 50 questions in 15 minutes.
If you are not ready to take this test, you can study here.
Match each statement with the correct term.
Don't refresh. All questions and answers are randomly picked and ordered every time you load a test.

This is a study tool. The 3 wrong answers for each question are randomly chosen from answers to other questions. So, you might find at times the answers obvious, but you will see it re-enforces your understanding as you take the test each time.

1. Fluid volume deficit is a __________ dx
Decision assessment
Nursing
Initial assessment
Inattention and acute increase/decrease in cognitive function

2. If patient reports pain of 3 on scale of 0-10 - What is the appropriate class of pain reliever?
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
Upper airways
Non - opiod (ex: NSAID/acetominaphen)
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy

3. When dealing with a confused patient - should the nurse acknowledge the patient's underlying feelings or the content of the delusion?

4. What is intermittent claudication?
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Decreased sense of taste
Defining a baseline of cognitive function - any changes or deviations from norm.
Pain in legs assoc w walking

5. When performing an interview with a patient with vision loss - select the correct questions for obtaining an accurate vision history
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Level of stress - risk for violence - anxiety level - patient unmet needs
Risk of falls increases
Serves to expedite dx and tx of actual and potential health problems

6. What are the ABCDE's of pain management?
Preschool is cause and effect - school age begins to use logical thought process.
Ongoing assessment
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Ask - Believe - Choose - Deliver - Empower

7. Sleep deprivation can effect
The patient
Paradoxical reaction
Learning - memory and adaptation to stress
Edema

8. Examples of personal information
School age childen
Irregular respirations (fast/slow) often seen at end of life
To ID the problem
Hygeine - DOB - work hx

9. What is the correct approach when dealing with older adults?
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Objective
Assess over all health status and identify the problem
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.

10. QUESTT is a tool for What type of an assessment?
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
Secondary soureces (family - friends)
ID'ing status of exisiting problems and locating new issues
Pain

11. If an abnormal finding is revealed during assessment - the nurse should
Bacterial infection
School age childen
Edema
Double check equip and patient

12. A patient that is dying is on morphine. The family is concerned the prs breathing will stop. What is the correct RN response?

13. The fifth vital sign is
Pain
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
No

14. The site where gas exchange occurs is
Capillaries
Have them do simple math problems
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts

15. What is the difference between a nursing dx and a med dx?
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
To ID the problem
Nursing
Decreased sense of taste

16. What do rhonchi sound like?
ID'ing status of exisiting problems and locating new issues
Pain
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Pt's underlying feelings

17. What is the nursing process?
Nursing
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Learning - memory and adaptation to stress
Decreased sense of taste

18. What is the purpose of the nursing process?
Serves to expedite dx and tx of actual and potential health problems
Nurse
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
Family - spouse - someone other than a healthcare worker - previous medical records.

19. What factors may indicate plural rub?
Communicate using hands and eyes.
Snap - crackle - pops; velcro - bubble wrap
Pain on inspiration and expiration; superficial squeaking or grating
Hemoglobin

20. What scale is used to determine eating and feeding issues in adults with confusion
Pain
EdFED- Q
Loss of taste
Fluid volume deficit related to poor intake

21. Describe the purpose of a mental status exam
Nursing dx
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Secondary
Defining a baseline of cognitive function - any changes or deviations from norm.

22. Inspiration sounds are heard longer than expiration sounds In What area?
ID'ing status of exisiting problems and locating new issues
Vesicular (peripheral lung areas)
Snap - crackle - pops; velcro - bubble wrap
Pain in legs assoc w walking

23. Data gathered via instrumention (pulse ox) is considered
Capillaries
Pain on inspiration and expiration; superficial squeaking or grating
Objective
Wandering

24. A nursing dx is best described as
EdFED- Q
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
To ID the problem
Stroke volume x's heart rate

25. The purpose of an intitial assement serves to?
Assess over all health status and identify the problem
Medical
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Data collection - data validation - data organization - data analysis - and data reporting/recording.

26. What does CAM stand for
Upper airways
Learning - memory and adaptation to stress
Confusion Assessment Method
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response

27. Kussamaul respirations describe

28. What would cause changes in congitive development later in life (middle adulthood)?
8.4
Trauma or illness
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
Secondary soureces (family - friends)

29. The path of blood from the heart to the lungs is
Decreased arterial perfusion
Hemoglobin
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Hearing loss

30. Nursing dx provides basis of
Trend assessment (shift report)
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Implementation
Interventions for which the nurse is accountable

31. At What age do you begin to use decision making?
Adolescence
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Learning - memory and adaptation to stress

32. What is the cognitive difference between a preschooler and schoolage child?
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Secondary soureces (family - friends)
Preschool is cause and effect - school age begins to use logical thought process.
Secondary

33. What are Piaget's stages of cognitive development
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
Bacterial infection
Pain
Learning - memory and adaptation to stress

34. A patient that is easily fatigued may have a HgB lab value of?
Focused
Symptoms
8.4
Adolescence

35. All body system data is not necessary which type of assessment
Trauma or illness
The patient
Pain on inspiration and expiration; superficial squeaking or grating
Focused

36. An ongoing assessment is performed
Daily
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
A personal experience that does whatever the person in pain says it does
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances

37. What are the steps of the nursing process?
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Hemoglobin

38. The basis for a plan of care comes for which stage of the nursing process?
Level of stress - risk for violence - anxiety level - patient unmet needs
Nursing dx
School age childen
Inattention and acute increase/decrease in cognitive function

39. When performing an ongoing assessment for a patient with disturbed thinking the nurse should be sure to include
Having to use more than one pillow when sleeping
Have them do simple math problems
Pain
Level of stress - risk for violence - anxiety level - patient unmet needs

40. What is the formula for cardiac output?

41. At What age do you begin to put thoughts into words?
Confusion Assessment Method
Fast and deep respirations seen in patient's with acidosis
Toddler
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.

42. Acceptable sources of assessment data when evaluating a confused patient would be
Data collection - data validation - data organization - data analysis - and data reporting/recording.
The process of storing - learning - retrieving - and using info.
Secondary soureces (family - friends)
# of packs per day x # of years smoked

43. Expiration sounds are heard longer than inspiration In What area?
Broncial (heard over trachea)
The result is accurate patient dB
Assess over all health status and identify the problem
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances

44. Why are young children at greater risk for respiratory infection?
Pt's with oxygenation and perfusion problems
Secondary soureces (family - friends)
Immature immune system - structures close together lends to easy spreading from on area to another.
A false - fixed belief that cannot be corrected through reasoning.

45. An example of a nursing dx would be
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Fast and deep respirations seen in patient's with acidosis
Fluid volume deficit related to poor intake
Vesicular (peripheral lung areas)

46. An infant is in which Paiget stage?
Initial assessment
Immature immune system - structures close together lends to easy spreading from on area to another.
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Sensory motor

47. An example of a primary source is
The patient
Double check equip and patient
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Toddler

48. Asking a patient what would you do if there is a fire in the wastebasket - is a way to assess their
The result is accurate patient dB
Serves to expedite dx and tx of actual and potential health problems
Level of stress - risk for violence - anxiety level - patient unmet needs
Abstract thinking

49. What is the difference between hallucination and delirium?
Preschool is cause and effect - school age begins to use logical thought process.
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
EdFED- Q

50. When a patient has increased neutrophils - this may indicate what?
Nursing
Bacterial infection
Adolescence
Trauma or illness