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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. Why are young children at greater risk for respiratory infection?
Knowing What to do/how to make a decision based upon available data.
Fluid volume deficit related to poor intake
Immature immune system - structures close together lends to easy spreading from on area to another.
A personal experience that does whatever the person in pain says it does

2. What are the components of an assessment?
Upper airways
Pain in legs assoc w walking
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Double check equip and patient

3. 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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4. A nursing dx is best described as
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Nursing
Ask - Believe - Choose - Deliver - Empower
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.

5. The fifth vital sign is
Pain
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Upper airways
Secondary soureces (family - friends)

6. Where can you hear bronchovesicular breath sounds?
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Focused
Knowing What to do/how to make a decision based upon available data.
Objective

7. Kussamaul respirations describe

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8. What is the difference between hallucination and delirium?
Snap - crackle - pops; velcro - bubble wrap
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Sensory motor
Inattention and acute increase/decrease in cognitive function

9. What is cognition?
Confusion Assessment Method
School age childen
The process of storing - learning - retrieving - and using info.
Irregular respirations (fast/slow) often seen at end of life

10. Hypogeusis is
Learning - memory and adaptation to stress
Adolescence
Decreased sense of taste
Level of stress - risk for violence - anxiety level - patient unmet needs

11. All body system data is not necessary which type of assessment
Focused
Secondary soureces (family - friends)
Sensory motor
Pain on inspiration and expiration; superficial squeaking or grating

12. Diabetes is a _________ dx
Learning - memory and adaptation to stress
School age childen
Focused
Medical

13. What are the steps of the nursing process?
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Trend assessment (shift report)
Ongoing assessment

14. What is a chochlear implant?
Vesicular (peripheral lung areas)
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Objective
Nursing dx

15. What are the components of a mental status exam that are not part of a regular assessment?
Pain
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.

16. Data gathered via instrumention (pulse ox) is considered
Objective
8.4
Nurse
Surgically implanted device for deaf or hard or hearing - also called bionic ear.

17. Where can wheezes best be heard?
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Upper airways
Tricuspid - mitral and the aortic
Ongoing assessment

18. What are Piaget's stages of cognitive development
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Capillaries
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)

19. At What age do you begin to use logical thought process?
School age childen
Disorganized thinking and altered LOC
Bacterial infection
Level of stress - risk for violence - anxiety level - patient unmet needs

20. What scale is used to determine eating and feeding issues in adults with confusion
EdFED- Q
Pt's with oxygenation and perfusion problems
Toddler
Data collection - data validation - data organization - data analysis - and data reporting/recording.

21. What factors may indicate plural rub?
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
A false - fixed belief that cannot be corrected through reasoning.
Pain on inspiration and expiration; superficial squeaking or grating
No

22. 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
EdFED- Q
Communicate using hands and eyes.
Daily

23. What is pain?
A personal experience that does whatever the person in pain says it does
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
8.4

24. Sleep deprivation can effect
Pain on inspiration and expiration; superficial squeaking or grating
Abstract thinking
Learning - memory and adaptation to stress
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.

25. Expiration sounds are heard longer than inspiration In What area?
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Broncial (heard over trachea)
Nursing dx
Hygeine - DOB - work hx

26. An example of a secondary source is
Ongoing assessment
Broncial (heard over trachea)
Snap - crackle - pops; velcro - bubble wrap
Family - spouse - someone other than a healthcare worker - previous medical records.

27. Orthopnea is described as?
Secondary
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
Having to use more than one pillow when sleeping
Capillaries

28. Nursing interventions should be based on who's theory?
Ask - Believe - Choose - Deliver - Empower
Broncial (heard over trachea)
Maslow
School age childen

29. Nursing dx provides basis of
Interventions for which the nurse is accountable
An 80 y/o patient that has emergency surgery
Hygeine - DOB - work hx
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)

30. Side effects of putting confused pts in restraints include
No
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli

31. What is the cognitive difference between a preschooler and schoolage child?
Preschool is cause and effect - school age begins to use logical thought process.
Secondary soureces (family - friends)
Paradoxical reaction
School age childen

32. What is the difference between a nursing dx and a med dx?
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Fluid volume deficit related to poor intake
Daily

33. What are the ABCDE's of pain management?
Sensory motor
Ask - Believe - Choose - Deliver - Empower
Immature immune system - structures close together lends to easy spreading from on area to another.
Decision assessment

34. What is the correct approach when dealing with older adults?
Double check equip and patient
Secondary soureces (family - friends)
Broncial (heard over trachea)
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response

35. An infant is in which Paiget stage?
Sensory motor
No
Communicate using hands and eyes.
Nurse

36. The assessment that includes the patient's overhall health status
Loss of taste
The process of storing - learning - retrieving - and using info.
Initial assessment
Non - opiod (ex: NSAID/acetominaphen)

37. Are changes in vital signs a reliable indicator of chronic pain?
Risk of falls increases
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
No
Wandering

38. Subjective data could include
Non - opiod (ex: NSAID/acetominaphen)
Symptoms
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Toddler

39. Describe the purpose of a mental status exam
Broncial (heard over trachea)
Defining a baseline of cognitive function - any changes or deviations from norm.
Nurse
Focused

40. An ongoing assessment is performed
Daily
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Learning - memory and adaptation to stress
Broncial (heard over trachea)

41. Data validation assures
The result is accurate patient dB
Risk of falls increases
Inattention and acute increase/decrease in cognitive function
Pt's with oxygenation and perfusion problems

42. The order of air flow into the lungs is
Symptoms
To simulate eating motions with the hands
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
No

43. An example of a nursing dx would be
8.4
A false - fixed belief that cannot be corrected through reasoning.
Fluid volume deficit related to poor intake
Focused

44. What is the nursing process?
The result is accurate patient dB
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Communicate using hands and eyes.
Pain on inspiration and expiration; superficial squeaking or grating

45. What do rales sound like?
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Communicate using hands and eyes.
Focused
Snap - crackle - pops; velcro - bubble wrap

46. What are Cheyne Stokes?
Sensory motor
Pt's underlying feelings
Irregular respirations (fast/slow) often seen at end of life
Hearing loss

47. Two indicators that are REQUIRED for classification via the CAM tool include
Risk of falls increases
Inattention and acute increase/decrease in cognitive function
Focused
Assess over all health status and identify the problem

48. The basis for a plan of care comes for which stage of the nursing process?
Focused
Secondary
Nursing dx
Pt's with oxygenation and perfusion problems

49. A potential adverse rx of chemically restraining a confused patient would be
Paradoxical reaction
Daily
Adolescence
Snap - crackle - pops; velcro - bubble wrap

50. The purpose of an initial assessment is
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
No
To ID the problem
Paradoxical reaction