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. Name the 5 'W's' of assessing a change in LOC
Hearing loss
Serves to expedite dx and tx of actual and potential health problems
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)


2. What is a component of the cognitive part of critical thinking skills?
Knowing What to do/how to make a decision based upon available data.
Objective
Non - opiod (ex: NSAID/acetominaphen)
Tricuspid - mitral and the aortic


3. Ageusia is
Maslow
Loss of taste
To ID the problem
The result is accurate patient dB


4. What do rales sound like?
The patient
Communicate using hands and eyes.
Serves to expedite dx and tx of actual and potential health problems
Snap - crackle - pops; velcro - bubble wrap


5. The fifth vital sign is
Pain
An 80 y/o patient that has emergency surgery
Broncial (heard over trachea)
Tricuspid - mitral and the aortic


6. What is the nursing process?
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Decision assessment
Initial assessment
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -


7. Hypogeusis is
Decreased sense of taste
Pain in legs assoc w walking
The process of storing - learning - retrieving - and using info.
Family - spouse - someone other than a healthcare worker - previous medical records.


8. What does CAM stand for
Wandering
Confusion Assessment Method
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.


9. What is the cognitive difference between a preschooler and schoolage child?
Preschool is cause and effect - school age begins to use logical thought process.
An 80 y/o patient that has emergency surgery
Having to use more than one pillow when sleeping
Initial assessment


10. Data gathered via instrumention (pulse ox) is considered
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
Pain on inspiration and expiration; superficial squeaking or grating
Ongoing assessment
Objective


11. When using restraints in a confused patient
8.4
Risk of falls increases
Viral infection
Toddler


12. Side effects of putting confused pts in restraints include
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
# of packs per day x # of years smoked
8.4


13. Acceptable sources of assessment data when evaluating a confused patient would be
The process of storing - learning - retrieving - and using info.
Have them do simple math problems
Pain in legs assoc w walking
Secondary soureces (family - friends)


14. What are the components of a mental status exam that are not part of a regular assessment?
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
Broncial (heard over trachea)
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Nurse


15. What is a chochlear implant?
An 80 y/o patient that has emergency surgery
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Interventions for which the nurse is accountable


16. Once a medical dx has been made - who is accountable for the reporting s/s of complications?
Fluid volume deficit related to poor intake
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
Symptoms
Nurse


17. QUESTT is a tool for What type of an assessment?
To ID the problem
Nurse
Pain
Hearing loss


18. Asking a patient what would you do if there is a fire in the wastebasket - is a way to assess their
Abstract thinking
Nursing dx
Secondary soureces (family - friends)
Data collection - data validation - data organization - data analysis - and data reporting/recording.


19. What is a definition of a delusion?
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
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
A false - fixed belief that cannot be corrected through reasoning.


20. When performing an interview with a patient with vision loss - select the correct questions for obtaining an accurate vision history
Symptoms
Have them do simple math problems
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Nurse


21. Where can wheezes best be heard?
Fluid volume deficit related to poor intake
The patient
Trauma or illness
Upper airways


22. Keeping patient's belongings - shoes - suitcases and street clothes - etc. out of view are helpful for preventing: wandering?
Implementation
A personal experience that does whatever the person in pain says it does
Immature immune system - structures close together lends to easy spreading from on area to another.
Wandering


23. When a patient has increased neutrophils - this may indicate what?
Pain
Ask - Believe - Choose - Deliver - Empower
Bacterial infection
Pain


24. Ongoing assessments are useful in

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

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26. When speaking with a patient with moderate hearing loss the RN should
Level of stress - risk for violence - anxiety level - patient unmet needs
Medical
Pt's underlying feelings
Communicate using hands and eyes.


27. Inspiration sounds are heard longer than expiration sounds In What area?
Vesicular (peripheral lung areas)
Knowing What to do/how to make a decision based upon available data.
Viral infection
Have them do simple math problems


28. Data from the last 24/48 hours that included patterns would be a part of
Trend assessment (shift report)
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
The medication will not affect the patient's breathing.
Stroke volume x's heart rate


29. What is the formula for determining pack years?
Bacterial infection
The process of storing - learning - retrieving - and using info.
# of packs per day x # of years smoked
Secondary


30. 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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31. The basis for a plan of care comes for which stage of the nursing process?
Viral infection
Pain in legs assoc w walking
Wandering
Nursing dx


32. If patient reports pain of 3 on scale of 0-10 - What is the appropriate class of pain reliever?
Secondary soureces (family - friends)
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
Non - opiod (ex: NSAID/acetominaphen)
The patient


33. At What age do you begin to use decision making?
Adolescence
Pt's underlying feelings
Bacterial infection
Nursing dx


34. What is intermittent claudication?
Pain in legs assoc w walking
Initial assessment
Secondary
Confusion Assessment Method


35. The path of blood from the heart to the lungs is
Nursing dx
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.
ID'ing status of exisiting problems and locating new issues


36. 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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37. Examples of personal information
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Family - spouse - someone other than a healthcare worker - previous medical records.
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Hygeine - DOB - work hx


38. Types of hearing loss include
Defining a baseline of cognitive function - any changes or deviations from norm.
Non - opiod (ex: NSAID/acetominaphen)
No
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)


39. Kussamaul respirations describe

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40. Sleep deprivation can effect
The process of storing - learning - retrieving - and using info.
Hygeine - DOB - work hx
Learning - memory and adaptation to stress
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -


41. A patient that is easily fatigued may have a HgB lab value of?
Tricuspid - mitral and the aortic
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
8.4
Snap - crackle - pops; velcro - bubble wrap


42. Intermittent claudication is caused by?
Decreased arterial perfusion
Immature immune system - structures close together lends to easy spreading from on area to another.
Secondary soureces (family - friends)
8.4


43. An example of a nursing dx would be
The process of storing - learning - retrieving - and using info.
8.4
Fluid volume deficit related to poor intake
Risk of falls increases


44. When a patient has increased lymphocytes - this may indicate what?
No
Viral infection
To ID the problem
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts


45. What are the steps of the nursing process?
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
To simulate eating motions with the hands
Non - opiod (ex: NSAID/acetominaphen)
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation


46. In Which part of the nursing process will you find delegation?
Having to use more than one pillow when sleeping
Implementation
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Assess over all health status and identify the problem


47. Orthopnea is described as?
Having to use more than one pillow when sleeping
Decision assessment
Hearing loss
Initial assessment


48. Other factors that may indicate confusion using the CAM tool could be
Ask - Believe - Choose - Deliver - Empower
Disorganized thinking and altered LOC
Pain on inspiration and expiration; superficial squeaking or grating
Trauma or illness


49. An ongoing assessment is performed
Toddler
An 80 y/o patient that has emergency surgery
Daily
Paradoxical reaction


50. The order of air flow into the lungs is
8.4
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
Wandering
Eye hygeine - accomodating factors - what was the level of decline - how long has it been