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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. Types of hearing loss include
Pain
Daily
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
Level of stress - risk for violence - anxiety level - patient unmet needs

2. What is the difference between a nursing dx and a med dx?
Medical
Nursing dx
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Bacterial infection

3. In Which part of the nursing process will you find delegation?
An 80 y/o patient that has emergency surgery
Implementation
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Pt's underlying feelings

4. Data that is recorded for an immediate need (code blue or fall) would be included in
Having to use more than one pillow when sleeping
Decision assessment
Secondary soureces (family - friends)
Paradoxical reaction

5. Expiration sounds are heard longer than inspiration In What area?
Level of stress - risk for violence - anxiety level - patient unmet needs
Objective
The patient
Broncial (heard over trachea)

6. QUESTT is a tool for What type of an assessment?
Initial assessment
Capillaries
Pain on inspiration and expiration; superficial squeaking or grating
Pain

7. Are changes in vital signs a reliable indicator of chronic pain?
Snap - crackle - pops; velcro - bubble wrap
No
School age childen
An 80 y/o patient that has emergency surgery

8. What is the nursing process?
The medication will not affect the patient's breathing.
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Loss of taste
Abstract thinking

9. What is responsible for transporting O2 in the blood
School age childen
Secondary
Decreased arterial perfusion
Hemoglobin

10. Sleep deprivation can effect
Nursing dx
Defining a baseline of cognitive function - any changes or deviations from norm.
Hemoglobin
Learning - memory and adaptation to stress

11. When noticing a patient with dementia has stopped eating - the RN's first response is?
Loss of taste
To simulate eating motions with the hands
Wandering
Stroke volume x's heart rate

12. When a patient has increased lymphocytes - this may indicate what?
Abstract thinking
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
Viral infection
Vesicular (peripheral lung areas)

13. What is the formula for cardiac output?

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14. Where can wheezes best be heard?
EdFED- Q
Upper airways
Broncial (heard over trachea)
The process of storing - learning - retrieving - and using info.

15. Name the 5 'W's' of assessing a change in LOC
Loss of taste
Nursing
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Double check equip and patient

16. What is the cognitive difference between a preschooler and schoolage child?
8.4
Knowing What to do/how to make a decision based upon available data.
Level of stress - risk for violence - anxiety level - patient unmet needs
Preschool is cause and effect - school age begins to use logical thought process.

17. Describe the purpose of a mental status exam
Focused
Defining a baseline of cognitive function - any changes or deviations from norm.
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Learning - memory and adaptation to stress

18. At What age do you begin to use decision making?
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Pain
Adolescence
Trend assessment (shift report)

19. Side effects of putting confused pts in restraints include
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Disorganized thinking and altered LOC
ID'ing status of exisiting problems and locating new issues

20. When performing an ongoing assessment for a patient with disturbed thinking the nurse should be sure to include
Level of stress - risk for violence - anxiety level - patient unmet needs
Hearing loss
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Have them do simple math problems

21. Orthopnea is described as?
Nurse
Immature immune system - structures close together lends to easy spreading from on area to another.
Pain in legs assoc w walking
Having to use more than one pillow when sleeping

22. At patient that state their shoes are tighter at the end of the day may be experiencing
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Hemoglobin
Edema
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)

23. An infant is in which Paiget stage?
Irregular respirations (fast/slow) often seen at end of life
Snap - crackle - pops; velcro - bubble wrap
Sensory motor
Hearing loss

24. Other factors that may indicate confusion using the CAM tool could be
Disorganized thinking and altered LOC
Viral 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)
Vesicular (peripheral lung areas)

25. What are the components of an assessment?
Pain
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
No
Data collection - data validation - data organization - data analysis - and data reporting/recording.

26. Nursing dx provides basis of
Stroke volume x's heart rate
Interventions for which the nurse is accountable
Level of stress - risk for violence - anxiety level - patient unmet needs
Decreased arterial perfusion

27. The basis for a plan of care comes for which stage of the nursing process?
Secondary
Irregular respirations (fast/slow) often seen at end of life
Nursing dx
Medical

28. A patient failing to answer questions or displaying a reluctance to participate in group or family activities may be experiencing
Symptoms
Ongoing assessment
Hearing loss
Paradoxical reaction

29. 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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30. Ongoing assessments are useful in

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31. When speaking with a patient with moderate hearing loss the RN should
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Communicate using hands and eyes.
Double check equip and patient
Fluid volume deficit related to poor intake

32. What is a chochlear implant?
Capillaries
Secondary
Initial assessment
Surgically implanted device for deaf or hard or hearing - also called bionic ear.

33. What is a definition of a delusion?
A false - fixed belief that cannot be corrected through reasoning.
Nursing dx
To ID the problem
ID'ing status of exisiting problems and locating new issues

34. Where can you hear bronchovesicular breath sounds?
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
School age childen
Level of stress - risk for violence - anxiety level - patient unmet needs
The medication will not affect the patient's breathing.

35. What factors may indicate plural rub?
Nursing
Wandering
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Pain on inspiration and expiration; superficial squeaking or grating

36. What is intermittent claudication?
Serves to expedite dx and tx of actual and potential health problems
Confusion Assessment Method
Abstract thinking
Pain in legs assoc w walking

37. Data gathered via instrumention (pulse ox) is considered
Preschool is cause and effect - school age begins to use logical thought process.
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Objective
# of packs per day x # of years smoked

38. Which patient would be most likely to experience sensory overload?
A personal experience that does whatever the person in pain says it does
To simulate eating motions with the hands
An 80 y/o patient that has emergency surgery
Trauma or illness

39. What scale is used to determine eating and feeding issues in adults with confusion
EdFED- Q
Double check equip and patient
Abstract thinking
Secondary

40. 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 -
Paradoxical reaction
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Stroke volume x's heart rate

41. Another term for a focused assessment is
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Having to use more than one pillow when sleeping
Ongoing assessment
The patient

42. What is the formula for determining pack years?
# of packs per day x # of years smoked
Broncial (heard over trachea)
Interventions for which the nurse is accountable
A false - fixed belief that cannot be corrected through reasoning.

43. When a patient has increased neutrophils - this may indicate what?
An 80 y/o patient that has emergency surgery
Bacterial infection
Trauma or illness
Decreased sense of taste

44. The order of air flow into the lungs is
Implementation
Hearing loss
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
Data collection - data validation - data organization - data analysis - and data reporting/recording.

45. The path of blood from the lungs to the heart is
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Learning - memory and adaptation to stress
Capillaries
The patient

46. An example of a secondary source is
Family - spouse - someone other than a healthcare worker - previous medical records.
To ID the problem
Implementation
Snap - crackle - pops; velcro - bubble wrap

47. Intermittent claudication is caused by?
Capillaries
Confusion Assessment Method
Decreased arterial perfusion
Secondary

48. Ageusia is
Loss of taste
Inattention and acute increase/decrease in cognitive function
Secondary soureces (family - friends)
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital

49. All body system data is not necessary which type of assessment
Pt's underlying feelings
Disorganized thinking and altered LOC
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
Focused

50. Keeping patient's belongings - shoes - suitcases and street clothes - etc. out of view are helpful for preventing: wandering?
Wandering
Nurse
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Family - spouse - someone other than a healthcare worker - previous medical records.