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. Keeping patient's belongings - shoes - suitcases and street clothes - etc. out of view are helpful for preventing: wandering?
Wandering
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Preschool is cause and effect - school age begins to use logical thought process.
School age childen


2. Orthopnea is described as?
Having to use more than one pillow when sleeping
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Decreased arterial perfusion
Interventions for which the nurse is accountable


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

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4. What is the correct approach when dealing with older adults?
Pain
Immature immune system - structures close together lends to easy spreading from on area to another.
Disorganized thinking and altered LOC
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response


5. At What age do you begin to use logical thought process?
School age childen
Risk of falls increases
Edema
The medication will not affect the patient's breathing.


6. A patient failing to answer questions or displaying a reluctance to participate in group or family activities may be experiencing
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
Hearing loss
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Immature immune system - structures close together lends to easy spreading from on area to another.


7. What are Cheyne Stokes?
Disorganized thinking and altered LOC
Irregular respirations (fast/slow) often seen at end of life
Family - spouse - someone other than a healthcare worker - previous medical records.
Pain in legs assoc w walking


8. Data from the last 24/48 hours that included patterns would be a part of
Trend assessment (shift report)
No
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Adolescence


9. Side effects of putting confused pts in restraints include
Pt's underlying feelings
Upper airways
A false - fixed belief that cannot be corrected through reasoning.
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy


10. The assessment that includes the patient's overhall health status
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Broncial (heard over trachea)
Initial assessment
Nursing


11. What scale is used to determine eating and feeding issues in adults with confusion
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Paradoxical reaction
Secondary soureces (family - friends)
EdFED- Q


12. The purpose of an initial assessment is
To ID the problem
Defining a baseline of cognitive function - any changes or deviations from norm.
Symptoms
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)


13. What does CAM stand for
Confusion Assessment Method
Preschool is cause and effect - school age begins to use logical thought process.
Nursing dx
Fluid volume deficit related to poor intake


14. 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 -
Ongoing assessment
Risk of falls increases
The patient


15. 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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16. Hypogeusis is
Irregular respirations (fast/slow) often seen at end of life
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Snap - crackle - pops; velcro - bubble wrap
Decreased sense of taste


17. What is responsible for transporting O2 in the blood
Focused
Hemoglobin
EdFED- Q
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.


18. Blood passes through the heart valves In what order?
No
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Tricuspid - mitral and the aortic
Immature immune system - structures close together lends to easy spreading from on area to another.


19. A patient that is easily fatigued may have a HgB lab value of?
Nursing
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
A false - fixed belief that cannot be corrected through reasoning.
8.4


20. What are the steps of the nursing process?
Defining a baseline of cognitive function - any changes or deviations from norm.
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Irregular respirations (fast/slow) often seen at end of life
A false - fixed belief that cannot be corrected through reasoning.


21. An example of a secondary source is
Family - spouse - someone other than a healthcare worker - previous medical records.
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Sensory motor
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)


22. What would cause changes in congitive development later in life (middle adulthood)?
A false - fixed belief that cannot be corrected through reasoning.
Trauma or illness
# of packs per day x # of years smoked
Irregular respirations (fast/slow) often seen at end of life


23. The site where gas exchange occurs is
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
The result is accurate patient dB
Secondary soureces (family - friends)
Capillaries


24. Intermittent claudication is caused by?
Learning - memory and adaptation to stress
Decreased arterial perfusion
The patient
Serves to expedite dx and tx of actual and potential health problems


25. What is the formula for cardiac output?

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26. If an abnormal finding is revealed during assessment - the nurse should
# of packs per day x # of years smoked
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
Tricuspid - mitral and the aortic
Double check equip and patient


27. The fifth vital sign is
Abstract thinking
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
Pain
Communicate using hands and eyes.


28. What are Piaget's stages of cognitive development
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.


29. Subjective data could include
The patient
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Inattention and acute increase/decrease in cognitive function
Symptoms


30. Ageusia is
Pain
Loss of taste
ID'ing status of exisiting problems and locating new issues
Wandering


31. A potential adverse rx of chemically restraining a confused patient would be
Paradoxical reaction
To simulate eating motions with the hands
Double check equip and patient
Disorganized thinking and altered LOC


32. 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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33. When using restraints in a confused patient
Risk of falls increases
Non - opiod (ex: NSAID/acetominaphen)
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
Toddler


34. Asking a patient what would you do if there is a fire in the wastebasket - is a way to assess their
Objective
Abstract thinking
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Sensory motor


35. When noticing a patient with dementia has stopped eating - the RN's first response is?
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Level of stress - risk for violence - anxiety level - patient unmet needs
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
To simulate eating motions with the hands


36. Inspiration sounds are heard longer than expiration sounds In What area?
Interventions for which the nurse is accountable
Vesicular (peripheral lung areas)
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Implementation


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


38. Are changes in vital signs a reliable indicator of chronic pain?
Nursing dx
Decreased sense of taste
No
Pain on inspiration and expiration; superficial squeaking or grating


39. Once a medical dx has been made - who is accountable for the reporting s/s of complications?
Pain
Nurse
Having to use more than one pillow when sleeping
No


40. A nursing dx is best described as
Capillaries
Upper airways
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
Fast and deep respirations seen in patient's with acidosis


41. When a patient has increased neutrophils - this may indicate what?
Initial assessment
Secondary soureces (family - friends)
Bacterial infection
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli


42. What factors may indicate plural rub?
Wandering
Pain on inspiration and expiration; superficial squeaking or grating
A personal experience that does whatever the person in pain says it does
Secondary


43. What are the ABCDE's of pain management?
Knowing What to do/how to make a decision based upon available data.
Ask - Believe - Choose - Deliver - Empower
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
The result is accurate patient dB


44. QUESTT is a tool for What type of an assessment?
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Pain
School age childen
Interventions for which the nurse is accountable


45. Describe the purpose of a mental status exam
Abstract thinking
The result is accurate patient dB
8.4
Defining a baseline of cognitive function - any changes or deviations from norm.


46. What are the components of an assessment?
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Data collection - data validation - data organization - data analysis - and data reporting/recording.
# of packs per day x # of years smoked
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)


47. Ongoing assessments are useful in

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48. An example of a primary source is
Paradoxical reaction
Viral infection
The patient
Capillaries


49. Nursing interventions should be based on who's theory?
Initial assessment
An 80 y/o patient that has emergency surgery
Nurse
Maslow


50. What is a component of the cognitive part of critical thinking skills?
Bacterial infection
Pain in legs assoc w walking
Secondary
Knowing What to do/how to make a decision based upon available data.