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

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2. A nursing dx is best described as
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
Abstract thinking
Fast and deep respirations seen in patient's with acidosis

3. Which patient would be most likely to experience sensory overload?
An 80 y/o patient that has emergency surgery
Interventions for which the nurse is accountable
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
A false - fixed belief that cannot be corrected through reasoning.

4. Are changes in vital signs a reliable indicator of chronic pain?
Trend assessment (shift report)
No
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
Maslow

5. What are Piaget's stages of cognitive development
Hearing loss
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Decreased sense of taste

6. What is responsible for transporting O2 in the blood
Hemoglobin
Irregular respirations (fast/slow) often seen at end of life
To ID the problem
Implementation

7. Nursing dx provides basis of
Viral infection
The process of storing - learning - retrieving - and using info.
Edema
Interventions for which the nurse is accountable

8. At What age do you begin to use logical thought process?
School age childen
Assess over all health status and identify the problem
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.

9. What is intermittent claudication?
Focused
Capillaries
Trauma or illness
Pain in legs assoc w walking

10. What is a definition of a delusion?
A false - fixed belief that cannot be corrected through reasoning.
Pain
Fluid volume deficit related to poor intake
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins

11. If an abnormal finding is revealed during assessment - the nurse should
Double check equip and patient
Serves to expedite dx and tx of actual and potential health problems
Nursing dx
An 80 y/o patient that has emergency surgery

12. What factors may indicate plural rub?
Fluid volume deficit related to poor intake
Pain on inspiration and expiration; superficial squeaking or grating
Ongoing assessment
EdFED- Q

13. Nursing interventions should be based on who's theory?
Communicate using hands and eyes.
Maslow
EdFED- Q
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy

14. Would a nursing dx be part of the primary or secondary dx?
Objective
Ongoing assessment
Hygeine - DOB - work hx
Secondary

15. The basis for a plan of care comes for which stage of the nursing process?
Stroke volume x's heart rate
Tricuspid - mitral and the aortic
Nursing dx
Eye hygeine - accomodating factors - what was the level of decline - how long has it been

16. Where can you hear bronchovesicular breath sounds?
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Initial assessment
Having to use more than one pillow when sleeping
Wandering

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

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18. The assessment that includes the patient's overhall health status
Ask - Believe - Choose - Deliver - Empower
Fluid volume deficit related to poor intake
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Initial assessment

19. 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
Adolescence
Upper airways
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins

20. A potential adverse rx of chemically restraining a confused patient would be
Hemoglobin
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Paradoxical reaction
Edema

21. Why are young children at greater risk for respiratory infection?
Immature immune system - structures close together lends to easy spreading from on area to another.
To ID the problem
Implementation
Focused

22. Expiration sounds are heard longer than inspiration In What area?
Broncial (heard over trachea)
Assess over all health status and identify the problem
Nurse
Nursing dx

23. Hypogeusis is
Pain on inspiration and expiration; superficial squeaking or grating
Decreased sense of taste
Interventions for which the nurse is accountable
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins

24. Side effects of putting confused pts in restraints include
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Knowing What to do/how to make a decision based upon available data.
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Secondary soureces (family - friends)

25. The purpose of an initial assessment is
To ID the problem
EdFED- Q
Secondary
Pain

26. Ongoing assessments are useful in

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27. An example of a nursing dx would be
Knowing What to do/how to make a decision based upon available data.
The patient
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Fluid volume deficit related to poor intake

28. Asking a patient what would you do if there is a fire in the wastebasket - is a way to assess their
Abstract thinking
Decreased arterial perfusion
Broncial (heard over trachea)
Pt's underlying feelings

29. Another term for a focused assessment is
Assess over all health status and identify the problem
Level of stress - risk for violence - anxiety level - patient unmet needs
Decreased arterial perfusion
Ongoing assessment

30. What are the components of a mental status exam that are not part of a regular assessment?
Secondary
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
The medication will not affect the patient's breathing.
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances

31. An infant is in which Paiget stage?
The process of storing - learning - retrieving - and using info.
Implementation
To simulate eating motions with the hands
Sensory motor

32. Acceptable sources of assessment data when evaluating a confused patient would be
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Hemoglobin
Secondary soureces (family - friends)

33. Describe the purpose of a mental status exam
Defining a baseline of cognitive function - any changes or deviations from norm.
Implementation
Double check equip and patient
To ID the problem

34. Data that is recorded for an immediate need (code blue or fall) would be included in
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
Stroke volume x's heart rate
Decision assessment
The process of storing - learning - retrieving - and using info.

35. What do rhonchi sound like?
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Defining a baseline of cognitive function - any changes or deviations from norm.
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts

36. Inspiration sounds are heard longer than expiration sounds In What area?
Pain in legs assoc w walking
Vesicular (peripheral lung areas)
Communicate using hands and eyes.
Serves to expedite dx and tx of actual and potential health problems

37. What is a component of the cognitive part of critical thinking skills?
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Knowing What to do/how to make a decision based upon available data.
Family - spouse - someone other than a healthcare worker - previous medical records.

38. The purpose of an intitial assement serves to?
School age childen
Wandering
Assess over all health status and identify the problem
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances

39. One way to test a person's cognitive ability and abstract thinking ability would be to
Nursing dx
Have them do simple math problems
Hemoglobin
Bacterial infection

40. Data validation assures
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
ID'ing status of exisiting problems and locating new issues
Medical
The result is accurate patient dB

41. A patient failing to answer questions or displaying a reluctance to participate in group or family activities may be experiencing
Sensory motor
To simulate eating motions with the hands
Hearing loss
Immature immune system - structures close together lends to easy spreading from on area to another.

42. At patient that state their shoes are tighter at the end of the day may be experiencing
The result is accurate patient dB
Edema
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
No

43. Types of hearing loss include
Broncial (heard over trachea)
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
EdFED- Q
Paradoxical reaction

44. In Which part of the nursing process will you find delegation?
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Implementation
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Objective

45. What is the nursing process?
Fluid volume deficit related to poor intake
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Ask - Believe - Choose - Deliver - Empower
Edema

46. When a patient has increased neutrophils - this may indicate what?
Trauma or illness
Bacterial infection
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve

47. If patient reports pain of 3 on scale of 0-10 - What is the appropriate class of pain reliever?
Non - opiod (ex: NSAID/acetominaphen)
Tricuspid - mitral and the aortic
Hygeine - DOB - work hx
Communicate using hands and eyes.

48. The order of air flow into the lungs is
No
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)

49. Factors that may reduce the efficacy of pulse oximetry include
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
No
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Decreased arterial perfusion

50. What are the steps of the nursing process?
Trauma or illness
Tricuspid - mitral and the aortic
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Immature immune system - structures close together lends to easy spreading from on area to another.