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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?
Immature immune system - structures close together lends to easy spreading from on area to another.
Medical
Interventions for which the nurse is accountable
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -

2. What are the components of a mental status exam that are not part of a regular assessment?
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Decision assessment
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
Double check equip and patient

3. The assessment that includes the patient's overhall health status
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
Initial assessment
Tricuspid - mitral and the aortic
Daily

4. What are the ABCDE's of pain management?
Pain
Ask - Believe - Choose - Deliver - Empower
Decreased sense of taste
Eye hygeine - accomodating factors - what was the level of decline - how long has it been

5. The path of blood from the lungs to the heart is
Learning - memory and adaptation to stress
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Edema
No

6. What are Piaget's stages of cognitive development
The patient
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
Preschool is cause and effect - school age begins to use logical thought process.
Daily

7. All body system data is not necessary which type of assessment
Pain
A personal experience that does whatever the person in pain says it does
Capillaries
Focused

8. Nursing interventions should be based on who's theory?
Knowing What to do/how to make a decision based upon available data.
Snap - crackle - pops; velcro - bubble wrap
Symptoms
Maslow

9. Fluid volume deficit is a __________ dx
Preschool is cause and effect - school age begins to use logical thought process.
A personal experience that does whatever the person in pain says it does
Nursing
Implementation

10. What is the correct approach when dealing with older adults?
Preschool is cause and effect - school age begins to use logical thought process.
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Medical
Toddler

11. QUESTT is a tool for What type of an assessment?
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Toddler
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Pain

12. Examples of personal information
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
Hygeine - DOB - work hx
Having to use more than one pillow when sleeping
Nurse

13. When a patient has increased lymphocytes - this may indicate what?
Toddler
Medical
Viral infection
Disorganized thinking and altered LOC

14. A patient that is easily fatigued may have a HgB lab value of?
To simulate eating motions with the hands
8.4
To ID the problem
Defining a baseline of cognitive function - any changes or deviations from norm.

15. Acceptable sources of assessment data when evaluating a confused patient would be
Wandering
Secondary soureces (family - friends)
Objective
Decreased sense of taste

16. Diabetes is a _________ dx
Non - opiod (ex: NSAID/acetominaphen)
Ongoing assessment
Medical
Family - spouse - someone other than a healthcare worker - previous medical records.

17. Ongoing assessments are useful in

18. What are the steps of the nursing process?
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Knowing What to do/how to make a decision based upon available data.
Bacterial infection

19. An ongoing assessment is performed
Daily
Focused
Confusion Assessment Method
Sensory motor

20. One way to test a person's cognitive ability and abstract thinking ability would be to
# of packs per day x # of years smoked
Paradoxical reaction
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
Have them do simple math problems

21. What is a definition of a delusion?
Secondary soureces (family - friends)
EdFED- Q
Nurse
A false - fixed belief that cannot be corrected through reasoning.

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

23. An example of a primary source is
Edema
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
The patient
Defining a baseline of cognitive function - any changes or deviations from norm.

24. The path of blood from the heart to the lungs is
The process of storing - learning - retrieving - and using info.
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
To ID the problem
Fluid volume deficit related to poor intake

25. Where can wheezes best be heard?
Abstract thinking
# of packs per day x # of years smoked
Decreased arterial perfusion
Upper airways

26. What factors may indicate plural rub?
Pain on inspiration and expiration; superficial squeaking or grating
School age childen
EdFED- Q
Broncial (heard over trachea)

27. Data validation assures
Toddler
Edema
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
The result is accurate patient dB

28. What do rales sound like?
Double check equip and patient
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Snap - crackle - pops; velcro - bubble wrap
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.

29. Ageusia is
Loss of taste
Data collection - data validation - data organization - data analysis - and data reporting/recording.
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Adolescence

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

31. An example of a nursing dx would be
Pain in legs assoc w walking
Fluid volume deficit related to poor intake
Interventions for which the nurse is accountable
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital

32. What is a chochlear implant?
Decreased sense of taste
Risk of falls increases
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Upper airways

33. The site where gas exchange occurs is
Bacterial infection
Disorganized thinking and altered LOC
Secondary
Capillaries

34. What is cognition?
Fluid volume deficit related to poor intake
Edema
The process of storing - learning - retrieving - and using info.
Pt's with oxygenation and perfusion problems

35. If an abnormal finding is revealed during assessment - the nurse should
Bacterial infection
Double check equip and patient
Pain
The patient

36. What is pain?
Bacterial infection
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
A personal experience that does whatever the person in pain says it does

37. Where can you hear bronchovesicular breath sounds?
Vesicular (peripheral lung areas)
To simulate eating motions with the hands
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Secondary soureces (family - friends)

38. The order of air flow into the lungs is
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
The process of storing - learning - retrieving - and using info.
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
Adolescence

39. An example of a secondary source is
Maslow
Family - spouse - someone other than a healthcare worker - previous medical records.
A personal experience that does whatever the person in pain says it does
Learning - memory and adaptation to stress

40. What is the cognitive difference between a preschooler and schoolage child?
Edema
Preschool is cause and effect - school age begins to use logical thought process.
Risk of falls increases
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital

41. Subjective data could include
Symptoms
# of packs per day x # of years smoked
Hearing loss
The process of storing - learning - retrieving - and using info.

42. Describe the purpose of a mental status exam
Decreased arterial perfusion
Fast and deep respirations seen in patient's with acidosis
Defining a baseline of cognitive function - any changes or deviations from norm.
Assess over all health status and identify the problem

43. Name the 5 'W's' of assessing a change in LOC
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Toddler
Assess over all health status and identify the problem

44. Inspiration sounds are heard longer than expiration sounds In What area?
No
Irregular respirations (fast/slow) often seen at end of life
Vesicular (peripheral lung areas)
Learning - memory and adaptation to stress

45. Which patient would be most likely to experience sensory overload?
An 80 y/o patient that has emergency surgery
Pain on inspiration and expiration; superficial squeaking or grating
Knowing What to do/how to make a decision based upon available data.
The medication will not affect the patient's breathing.

46. The fifth vital sign is
To ID the problem
EdFED- Q
Pain
The process of storing - learning - retrieving - and using info.

47. What is responsible for transporting O2 in the blood
The medication will not affect the patient's breathing.
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Hemoglobin
Learning - memory and adaptation to stress

48. Once a medical dx has been made - who is accountable for the reporting s/s of complications?
Decreased sense of taste
Pain
Nurse
Sensory motor

49. Blood passes through the heart valves In what order?
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Knowing What to do/how to make a decision based upon available data.
Tricuspid - mitral and the aortic
Disorganized thinking and altered LOC

50. What does CAM stand for
Confusion Assessment Method
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Trend assessment (shift report)
Level of stress - risk for violence - anxiety level - patient unmet needs