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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. A potential adverse rx of chemically restraining a confused patient would be
Pt's underlying feelings
Pain
Paradoxical reaction
Pain

2. A patient that is easily fatigued may have a HgB lab value of?
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
8.4
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Nursing dx

3. 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.
Disorganized thinking and altered LOC
A personal experience that does whatever the person in pain says it does
Having to use more than one pillow when sleeping

4. An infant is in which Paiget stage?
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
Sensory motor
Interventions for which the nurse is accountable
Decision assessment

5. What are the components of an assessment?
Risk of falls increases
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy

6. Factors that may reduce the efficacy of pulse oximetry include
Toddler
Pain
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)

7. What are Cheyne Stokes?
Broncial (heard over trachea)
Irregular respirations (fast/slow) often seen at end of life
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Secondary

8. Nursing interventions should be based on who's theory?
Maslow
Assess over all health status and identify the problem
# of packs per day x # of years smoked
Irregular respirations (fast/slow) often seen at end of life

9. If patient reports pain of 3 on scale of 0-10 - What is the appropriate class of pain reliever?
Double check equip and patient
Non - opiod (ex: NSAID/acetominaphen)
Sensory motor
Having to use more than one pillow when sleeping

10. Asking a patient what would you do if there is a fire in the wastebasket - is a way to assess their
Abstract thinking
A false - fixed belief that cannot be corrected through reasoning.
Pain on inspiration and expiration; superficial squeaking or grating
To simulate eating motions with the hands

11. The order of air flow into the lungs is
Vesicular (peripheral lung areas)
Paradoxical reaction
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
Inattention and acute increase/decrease in cognitive function

12. 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
Symptoms
Learning - memory and adaptation to stress
Wandering

13. Other factors that may indicate confusion using the CAM tool could be
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Tricuspid - mitral and the aortic
A false - fixed belief that cannot be corrected through reasoning.
Disorganized thinking and altered LOC

14. What is the nursing process?
To ID the problem
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Nursing

15. What would cause changes in congitive development later in life (middle adulthood)?
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
Trauma or illness
To ID the problem
Pain

16. Data from the last 24/48 hours that included patterns would be a part of
Trend assessment (shift report)
Fast and deep respirations seen in patient's with acidosis
Preschool is cause and effect - school age begins to use logical thought process.
Nursing dx

17. Where can wheezes best be heard?
Upper airways
Decision assessment
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Trauma or illness

18. What is pain?
Inattention and acute increase/decrease in cognitive function
A personal experience that does whatever the person in pain says it does
Nursing dx
Daily

19. Expiration sounds are heard longer than inspiration In What area?
Broncial (heard over trachea)
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Disorganized thinking and altered LOC
Communicate using hands and eyes.

20. What is the difference between hallucination and delirium?
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
Immature immune system - structures close together lends to easy spreading from on area to another.
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.

21. Two indicators that are REQUIRED for classification via the CAM tool include
Pt's with oxygenation and perfusion problems
Pain
EdFED- Q
Inattention and acute increase/decrease in cognitive function

22. The purpose of an intitial assement serves to?
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Assess over all health status and identify the problem
Secondary soureces (family - friends)
Risk of falls increases

23. What are the ABCDE's of pain management?
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Ask - Believe - Choose - Deliver - Empower
Paradoxical reaction
Sensory motor

24. In Which part of the nursing process will you find delegation?
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Implementation
Decreased arterial perfusion
Data collection - data validation - data organization - data analysis - and data reporting/recording.

25. Data gathered via instrumention (pulse ox) is considered
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Hemoglobin
Nurse
Objective

26. When noticing a patient with dementia has stopped eating - the RN's first response is?
School age childen
Tricuspid - mitral and the aortic
Stroke volume x's heart rate
To simulate eating motions with the hands

27. At What age do you begin to use logical thought process?
School age childen
No
Medical
Hemoglobin

28. When dealing with a confused patient - should the nurse acknowledge the patient's underlying feelings or the content of the delusion?

29. Orthopnea is described as?
Decreased sense of taste
Confusion Assessment Method
Bacterial infection
Having to use more than one pillow when sleeping

30. An ongoing assessment is performed
Hygeine - DOB - work hx
Pt's underlying feelings
Daily
Inattention and acute increase/decrease in cognitive function

31. The basis for a plan of care comes for which stage of the nursing process?
Nursing dx
Assess over all health status and identify the problem
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Wandering

32. One way to test a person's cognitive ability and abstract thinking ability would be to
Have them do simple math problems
Trend assessment (shift report)
Pain in legs assoc w walking
Initial assessment

33. Types of hearing loss include
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
EdFED- Q
Viral infection
Data collection - data validation - data organization - data analysis - and data reporting/recording.

34. Where can you hear bronchovesicular breath sounds?
Nursing
The result is accurate patient dB
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -

35. What is the difference between a nursing dx and a med dx?
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
Decreased arterial perfusion
Irregular respirations (fast/slow) often seen at end of life

36. Subjective data could include
Focused
Symptoms
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Capillaries

37. What is a definition of a delusion?
A false - fixed belief that cannot be corrected through reasoning.
Hemoglobin
Symptoms
Knowing What to do/how to make a decision based upon available data.

38. A nursing dx is best described as
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
Inattention and acute increase/decrease in cognitive function
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
To simulate eating motions with the hands

39. What are Piaget's stages of cognitive development
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
Loss of taste
Ongoing assessment
Tricuspid - mitral and the aortic

40. Sleep deprivation can effect
An 80 y/o patient that has emergency surgery
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Capillaries
Learning - memory and adaptation to stress

41. What are the components of a mental status exam that are not part of a regular assessment?
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
Hearing loss
Preschool is cause and effect - school age begins to use logical thought process.

42. When a patient has increased neutrophils - this may indicate what?
Bacterial infection
Viral infection
Hemoglobin
No

43. What factors may indicate plural rub?
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
Interventions for which the nurse is accountable
Daily
Pain on inspiration and expiration; superficial squeaking or grating

44. Another term for a focused assessment is
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Trauma or illness
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Ongoing assessment

45. When speaking with a patient with moderate hearing loss the RN should
To simulate eating motions with the hands
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Communicate using hands and eyes.
School age childen

46. The path of blood from the lungs to the heart is
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Inattention and acute increase/decrease in cognitive function
Snap - crackle - pops; velcro - bubble wrap
Non - opiod (ex: NSAID/acetominaphen)

47. What do rales sound like?
Paradoxical reaction
Snap - crackle - pops; velcro - bubble wrap
Pain on inspiration and expiration; superficial squeaking or grating
Hearing loss

48. Kussamaul respirations describe

49. Describe the purpose of a mental status exam
Abstract thinking
To ID the problem
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Defining a baseline of cognitive function - any changes or deviations from norm.

50. Intermittent claudication is caused by?
Implementation
Hemoglobin
Decreased arterial perfusion
A false - fixed belief that cannot be corrected through reasoning.