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Nursing Fundamentals 3

Instructions:

Answer 50 questions in 15 minutes.
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Match each statement with the correct term.
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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. What is a chochlear implant?
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Irregular respirations (fast/slow) often seen at end of life

2. What is the nursing process?
Viral infection
Vesicular (peripheral lung areas)
Toddler
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.

3. When using restraints in a confused patient
Pt's with oxygenation and perfusion problems
Medical
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Risk of falls increases

4. Keeping patient's belongings - shoes - suitcases and street clothes - etc. out of view are helpful for preventing: wandering?
# of packs per day x # of years smoked
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
Confusion Assessment Method
Wandering

5. When a patient has increased neutrophils - this may indicate what?
Bacterial infection
Knowing What to do/how to make a decision based upon available data.
Ongoing assessment
Data collection - data validation - data organization - data analysis - and data reporting/recording.

6. What is cognition?
Pain
Communicate using hands and eyes.
The process of storing - learning - retrieving - and using info.
Paradoxical reaction

7. Hypogeusis is
The patient
Decreased sense of taste
Pain
Trend assessment (shift report)

8. At What age do you begin to use logical thought process?
School age childen
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
The medication will not affect the patient's breathing.
An 80 y/o patient that has emergency surgery

9. Are changes in vital signs a reliable indicator of chronic pain?
Knowing What to do/how to make a decision based upon available data.
Broncial (heard over trachea)
No
Nursing dx

10. Ongoing assessments are useful in

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11. What is the difference between hallucination and delirium?
Risk of falls increases
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Double check equip and patient
Maslow

12. A potential adverse rx of chemically restraining a confused patient would be
Abstract thinking
Interventions for which the nurse is accountable
Paradoxical reaction
Defining a baseline of cognitive function - any changes or deviations from norm.

13. What would cause changes in congitive development later in life (middle adulthood)?
Wandering
Medical
Trauma or illness
Assess over all health status and identify the problem

14. Once a medical dx has been made - who is accountable for the reporting s/s of complications?
Confusion Assessment Method
Nurse
Pain in legs assoc w walking
Capillaries

15. Blood passes through the heart valves In what order?
Secondary
Pain
Tricuspid - mitral and the aortic
Surgically implanted device for deaf or hard or hearing - also called bionic ear.

16. At What age do you begin to use decision making?
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Ongoing assessment
Adolescence
Secondary soureces (family - friends)

17. The path of blood from the heart to the lungs is
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Nursing dx
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Pain

18. Intermittent claudication is caused by?
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Learning - memory and adaptation to stress
Decreased arterial perfusion
Immature immune system - structures close together lends to easy spreading from on area to another.

19. An example of a nursing dx would be
No
Abstract thinking
Fluid volume deficit related to poor intake
Nursing dx

20. Two indicators that are REQUIRED for classification via the CAM tool include
Knowing What to do/how to make a decision based upon available data.
Abstract thinking
Inattention and acute increase/decrease in cognitive function
Serves to expedite dx and tx of actual and potential health problems

21. Diabetes is a _________ dx
Medical
Hemoglobin
Wandering
The medication will not affect the patient's breathing.

22. Data gathered via instrumention (pulse ox) is considered
Objective
Toddler
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Bacterial infection

23. If an abnormal finding is revealed during assessment - the nurse should
Disorganized thinking and altered LOC
Tricuspid - mitral and the aortic
Double check equip and patient
Hygeine - DOB - work hx

24. Where can you hear bronchovesicular breath sounds?
Focused
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Pain
ID'ing status of exisiting problems and locating new issues

25. An infant is in which Paiget stage?
Pt's underlying feelings
School age childen
Family - spouse - someone other than a healthcare worker - previous medical records.
Sensory motor

26. ABG's would be an important lab value for What types of patient's?

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27. Factors that may reduce the efficacy of pulse oximetry include
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Disorganized thinking and altered LOC
Capillaries
The process of storing - learning - retrieving - and using info.

28. One way to test a person's cognitive ability and abstract thinking ability would be to
Have them do simple math problems
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Loss of taste

29. Sleep deprivation can effect
The patient
Learning - memory and adaptation to stress
EdFED- Q
To ID the problem

30. What is intermittent claudication?
Ongoing assessment
Initial assessment
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Pain in legs assoc w walking

31. The site where gas exchange occurs is
Capillaries
Having to use more than one pillow when sleeping
School age childen
Eye hygeine - accomodating factors - what was the level of decline - how long has it been

32. What are the components of a mental status exam that are not part of a regular assessment?
Hearing loss
Communicate using hands and eyes.
Learning - memory and adaptation to stress
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances

33. Subjective data could include
Symptoms
Trend assessment (shift report)
Initial assessment
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response

34. What is pain?
Secondary soureces (family - friends)
A personal experience that does whatever the person in pain says it does
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy

35. What scale is used to determine eating and feeding issues in adults with confusion
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
EdFED- Q
To ID the problem

36. Would a nursing dx be part of the primary or secondary dx?
Secondary
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
The process of storing - learning - retrieving - and using info.
Disorganized thinking and altered LOC

37. Orthopnea is described as?
A false - fixed belief that cannot be corrected through reasoning.
Loss of taste
Having to use more than one pillow when sleeping
Broncial (heard over trachea)

38. The purpose of an intitial assement serves to?
Assess over all health status and identify the problem
8.4
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)

39. A patient that is easily fatigued may have a HgB lab value of?
Adolescence
8.4
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Pt's underlying feelings

40. Data validation assures
Irregular respirations (fast/slow) often seen at end of life
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
The result is accurate patient dB
Nurse

41. A patient failing to answer questions or displaying a reluctance to participate in group or family activities may be experiencing
Hearing loss
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
Serves to expedite dx and tx of actual and potential health problems
Abstract thinking

42. The fifth vital sign is
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Pain
Fast and deep respirations seen in patient's with acidosis
A personal experience that does whatever the person in pain says it does

43. Where can wheezes best be heard?
Daily
Upper airways
Trauma or illness
Data collection - data validation - data organization - data analysis - and data reporting/recording.

44. In Which part of the nursing process will you find delegation?
Immature immune system - structures close together lends to easy spreading from on area to another.
Level of stress - risk for violence - anxiety level - patient unmet needs
Implementation
Eye hygeine - accomodating factors - what was the level of decline - how long has it been

45. If patient reports pain of 3 on scale of 0-10 - What is the appropriate class of pain reliever?
Irregular respirations (fast/slow) often seen at end of life
Non - opiod (ex: NSAID/acetominaphen)
Implementation
A false - fixed belief that cannot be corrected through reasoning.

46. What is the difference between a nursing dx and a med dx?
Toddler
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
The process of storing - learning - retrieving - and using info.
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital

47. QUESTT is a tool for What type of an assessment?
Loss of taste
Level of stress - risk for violence - anxiety level - patient unmet needs
Pain
8.4

48. What is the purpose of the nursing process?
Secondary soureces (family - friends)
Fast and deep respirations seen in patient's with acidosis
Knowing What to do/how to make a decision based upon available data.
Serves to expedite dx and tx of actual and potential health problems

49. Asking a patient what would you do if there is a fire in the wastebasket - is a way to assess their
Paradoxical reaction
Viral infection
Abstract thinking
Ongoing assessment

50. What is a component of the cognitive part of critical thinking skills?
Defining a baseline of cognitive function - any changes or deviations from norm.
Confusion Assessment Method
Knowing What to do/how to make a decision based upon available data.
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)

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Nursing Fundamentals 3

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