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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. When speaking with a patient with moderate hearing loss the RN should
Communicate using hands and eyes.
EdFED- Q
Pt's with oxygenation and perfusion problems
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -

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

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3. What is the nursing process?
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Adolescence
Risk of falls increases
Preschool is cause and effect - school age begins to use logical thought process.

4. At What age do you begin to use logical thought process?
Secondary soureces (family - friends)
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
School age childen

5. A nursing dx is best described as
Snap - crackle - pops; velcro - bubble wrap
Fluid volume deficit related to poor intake
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
The medication will not affect the patient's breathing.

6. Data that is recorded for an immediate need (code blue or fall) would be included in
Decision assessment
Defining a baseline of cognitive function - any changes or deviations from norm.
Trend assessment (shift report)
Wandering

7. When performing an interview with a patient with vision loss - select the correct questions for obtaining an accurate vision history
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
Maslow
Symptoms
Eye hygeine - accomodating factors - what was the level of decline - how long has it been

8. All body system data is not necessary which type of assessment
Focused
A false - fixed belief that cannot be corrected through reasoning.
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Paradoxical reaction

9. Another term for a focused assessment is
Fluid volume deficit related to poor intake
Ongoing assessment
Viral infection
To simulate eating motions with the hands

10. Are changes in vital signs a reliable indicator of chronic pain?
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
No
An 80 y/o patient that has emergency surgery
Viral infection

11. An example of a nursing dx would be
Fluid volume deficit related to poor intake
Snap - crackle - pops; velcro - bubble wrap
Learning - memory and adaptation to stress
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve

12. What is the difference between hallucination and delirium?
Edema
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Decreased arterial perfusion
Nurse

13. Acceptable sources of assessment data when evaluating a confused patient would be
Assess over all health status and identify the problem
Pain on inspiration and expiration; superficial squeaking or grating
Family - spouse - someone other than a healthcare worker - previous medical records.
Secondary soureces (family - friends)

14. When using restraints in a confused patient
Having to use more than one pillow when sleeping
No
Trauma or illness
Risk of falls increases

15. The order of air flow into the lungs is
Pt's with oxygenation and perfusion problems
A personal experience that does whatever the person in pain says it does
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.

16. Examples of personal information
Stroke volume x's heart rate
Hygeine - DOB - work hx
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Pain on inspiration and expiration; superficial squeaking or grating

17. Keeping patient's belongings - shoes - suitcases and street clothes - etc. out of view are helpful for preventing: wandering?
Secondary
Trauma or illness
8.4
Wandering

18. What does CAM stand for
Pt's underlying feelings
8.4
Confusion Assessment Method
Pain on inspiration and expiration; superficial squeaking or grating

19. Subjective data could include
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Symptoms
Medical
Level of stress - risk for violence - anxiety level - patient unmet needs

20. 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
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Family - spouse - someone other than a healthcare worker - previous medical records.

21. Why are young children at greater risk for respiratory infection?
Risk of falls increases
Sensory motor
Fluid volume deficit related to poor intake
Immature immune system - structures close together lends to easy spreading from on area to another.

22. The basis for a plan of care comes for which stage of the nursing process?
Hygeine - DOB - work hx
Nursing dx
Stroke volume x's heart rate
Defining a baseline of cognitive function - any changes or deviations from norm.

23. Orthopnea is described as?
An 80 y/o patient that has emergency surgery
Having to use more than one pillow when sleeping
Implementation
The process of storing - learning - retrieving - and using info.

24. Expiration sounds are heard longer than inspiration In What area?
ID'ing status of exisiting problems and locating new issues
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
Broncial (heard over trachea)
No

25. What are Piaget's stages of cognitive development
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
Capillaries
Toddler
Communicate using hands and eyes.

26. Inspiration sounds are heard longer than expiration sounds In What area?
Irregular respirations (fast/slow) often seen at end of life
Serves to expedite dx and tx of actual and potential health problems
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Vesicular (peripheral lung areas)

27. An ongoing assessment is performed
Daily
Upper airways
Toddler
To ID the problem

28. Data gathered via instrumention (pulse ox) is considered
To simulate eating motions with the hands
Learning - memory and adaptation to stress
Stroke volume x's heart rate
Objective

29. An infant is in which Paiget stage?
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Confusion Assessment Method
Sensory motor
EdFED- Q

30. What are Cheyne Stokes?
Double check equip and patient
Irregular respirations (fast/slow) often seen at end of life
Symptoms
Nursing dx

31. Asking a patient what would you do if there is a fire in the wastebasket - is a way to assess their
Abstract thinking
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Focused

32. An example of a secondary source is
Edema
Family - spouse - someone other than a healthcare worker - previous medical records.
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)

33. Ongoing assessments are useful in

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34. Ageusia is
Interventions for which the nurse is accountable
Broncial (heard over trachea)
Loss of taste
Learning - memory and adaptation to stress

35. Intermittent claudication is caused by?
EdFED- Q
Upper airways
Stroke volume x's heart rate
Decreased arterial perfusion

36. What is a definition of a delusion?
The patient
A false - fixed belief that cannot be corrected through reasoning.
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Learning - memory and adaptation to stress

37. What is the correct approach when dealing with older adults?
8.4
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Serves to expedite dx and tx of actual and potential health problems
Vesicular (peripheral lung areas)

38. Nursing dx provides basis of
Interventions for which the nurse is accountable
Maslow
Inattention and acute increase/decrease in cognitive function
Have them do simple math problems

39. 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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40. What is responsible for transporting O2 in the blood
Bacterial infection
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Sensory motor
Hemoglobin

41. Factors that may reduce the efficacy of pulse oximetry include
Ask - Believe - Choose - Deliver - Empower
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Double check equip and patient
An 80 y/o patient that has emergency surgery

42. An example of a primary source is
The patient
Upper airways
Secondary soureces (family - friends)
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)

43. Fluid volume deficit is a __________ dx
Immature immune system - structures close together lends to easy spreading from on area to another.
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Nursing
Decreased sense of taste

44. A potential adverse rx of chemically restraining a confused patient would be
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Paradoxical reaction
Risk of falls increases
The medication will not affect the patient's breathing.

45. Describe the purpose of a mental status exam
Decreased arterial perfusion
Learning - memory and adaptation to stress
Defining a baseline of cognitive function - any changes or deviations from norm.
No

46. Would a nursing dx be part of the primary or secondary dx?
A false - fixed belief that cannot be corrected through reasoning.
Pain in legs assoc w walking
Secondary
Hearing loss

47. What would cause changes in congitive development later in life (middle adulthood)?
Wandering
Viral infection
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Trauma or illness

48. The path of blood from the lungs to the heart is
Having to use more than one pillow when sleeping
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
The patient
To simulate eating motions with the hands

49. 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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50. What scale is used to determine eating and feeding issues in adults with confusion
EdFED- Q
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Viral infection
Serves to expedite dx and tx of actual and potential health problems