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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. What is the difference between a nursing dx and a med dx?
Pain
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Having to use more than one pillow when sleeping

2. The path of blood from the lungs to the heart is
The patient
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Preschool is cause and effect - school age begins to use logical thought process.

3. What are the components of a mental status exam that are not part of a regular assessment?
Medical
Toddler
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.

4. What is cognition?
Disorganized thinking and altered LOC
Pt's underlying feelings
Decreased arterial perfusion
The process of storing - learning - retrieving - and using info.

5. What is intermittent claudication?
Tricuspid - mitral and the aortic
Hearing loss
Pain in legs assoc w walking
Fluid volume deficit related to poor intake

6. Inspiration sounds are heard longer than expiration sounds In What area?
Decreased arterial perfusion
Decision assessment
Vesicular (peripheral lung areas)
Initial assessment

7. What is a chochlear implant?
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Pt's underlying feelings
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Daily

8. What is the cognitive difference between a preschooler and schoolage child?
Double check equip and patient
Preschool is cause and effect - school age begins to use logical thought process.
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Vesicular (peripheral lung areas)

9. The purpose of an initial assessment is
Bacterial infection
Interventions for which the nurse is accountable
Vesicular (peripheral lung areas)
To ID the problem

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

11. Nursing dx provides basis of
Fluid volume deficit related to poor intake
An 80 y/o patient that has emergency surgery
Interventions for which the nurse is accountable
Knowing What to do/how to make a decision based upon available data.

12. When using restraints in a confused patient
Vesicular (peripheral lung areas)
Secondary soureces (family - friends)
Risk of falls increases
Edema

13. Sleep deprivation can effect
Hearing loss
Symptoms
Learning - memory and adaptation to stress
Knowing What to do/how to make a decision based upon available data.

14. One way to test a person's cognitive ability and abstract thinking ability would be to
Have them do simple math problems
Serves to expedite dx and tx of actual and potential health problems
Confusion Assessment Method
Non - opiod (ex: NSAID/acetominaphen)

15. What are Cheyne Stokes?
Paradoxical reaction
Irregular respirations (fast/slow) often seen at end of life
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Data collection - data validation - data organization - data analysis - and data reporting/recording.

16. At What age do you begin to use logical thought process?
School age childen
Implementation
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
To ID the problem

17. Data gathered via instrumention (pulse ox) is considered
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
Non - opiod (ex: NSAID/acetominaphen)
Objective

18. Describe the purpose of a mental status exam
Hygeine - DOB - work hx
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Defining a baseline of cognitive function - any changes or deviations from norm.

19. Are changes in vital signs a reliable indicator of chronic pain?
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Sensory motor
Risk of falls increases
No

20. Another term for a focused assessment is
Ongoing assessment
Stroke volume x's heart rate
Confusion Assessment Method
Decision assessment

21. What are the steps of the nursing process?
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
Secondary soureces (family - friends)
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Adolescence

22. A patient that is easily fatigued may have a HgB lab value of?
8.4
Medical
No
Maslow

23. Where can you hear bronchovesicular breath sounds?
Medical
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
ID'ing status of exisiting problems and locating new issues
Decision assessment

24. When performing an ongoing assessment for a patient with disturbed thinking the nurse should be sure to include
Pain
Non - opiod (ex: NSAID/acetominaphen)
Serves to expedite dx and tx of actual and potential health problems
Level of stress - risk for violence - anxiety level - patient unmet needs

25. At What age do you begin to put thoughts into words?
Pain on inspiration and expiration; superficial squeaking or grating
Hemoglobin
Knowing What to do/how to make a decision based upon available data.
Toddler

26. Data from the last 24/48 hours that included patterns would be a part of
Inattention and acute increase/decrease in cognitive function
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Trend assessment (shift report)

27. In Which part of the nursing process will you find delegation?
Loss of taste
Implementation
8.4
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins

28. What is the formula for cardiac output?

29. Which patient would be most likely to experience sensory overload?
Decreased arterial perfusion
A personal experience that does whatever the person in pain says it does
Nurse
An 80 y/o patient that has emergency surgery

30. Intermittent claudication is caused by?
Decreased arterial perfusion
School age childen
Inattention and acute increase/decrease in cognitive function
Preschool is cause and effect - school age begins to use logical thought process.

31. The order of air flow into the lungs is
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
Implementation
Pain
Tricuspid - mitral and the aortic

32. When a patient has increased lymphocytes - this may indicate what?
Viral infection
Bacterial infection
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
Family - spouse - someone other than a healthcare worker - previous medical records.

33. 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.
Medical
Loss of taste
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli

34. 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 -
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Preschool is cause and effect - school age begins to use logical thought process.
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)

35. Expiration sounds are heard longer than inspiration In What area?
Preschool is cause and effect - school age begins to use logical thought process.
Broncial (heard over trachea)
The result is accurate patient dB
Serves to expedite dx and tx of actual and potential health problems

36. Two indicators that are REQUIRED for classification via the CAM tool include
The result is accurate patient dB
Inattention and acute increase/decrease in cognitive function
Bacterial infection
Nursing

37. A potential adverse rx of chemically restraining a confused patient would be
Decreased sense of taste
Paradoxical reaction
Initial assessment
Pain

38. What does CAM stand for
Learning - memory and adaptation to stress
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Confusion Assessment Method
Pain

39. Subjective data could include
Tricuspid - mitral and the aortic
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.
Symptoms

40. The site where gas exchange occurs is
Capillaries
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Pain
ID'ing status of exisiting problems and locating new issues

41. What do rhonchi sound like?
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Snap - crackle - pops; velcro - bubble wrap
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Double check equip and patient

42. Where can wheezes best be heard?
Learning - memory and adaptation to stress
Upper airways
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Pain in legs assoc w walking

43. Blood passes through the heart valves In what order?
Hygeine - DOB - work hx
Capillaries
Hemoglobin
Tricuspid - mitral and the aortic

44. Acceptable sources of assessment data when evaluating a confused patient would be
Secondary soureces (family - friends)
Ongoing assessment
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
The result is accurate patient dB

45. Nursing interventions should be based on who's theory?
Tricuspid - mitral and the aortic
Maslow
The patient
Pain on inspiration and expiration; superficial squeaking or grating

46. All body system data is not necessary which type of assessment
Immature immune system - structures close together lends to easy spreading from on area to another.
Inattention and acute increase/decrease in cognitive function
No
Focused

47. Orthopnea is described as?
Initial assessment
Adolescence
Having to use more than one pillow when sleeping
An 80 y/o patient that has emergency surgery

48. What scale is used to determine eating and feeding issues in adults with confusion
Irregular respirations (fast/slow) often seen at end of life
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
EdFED- Q
Fluid volume deficit related to poor intake

49. What is a component of the cognitive part of critical thinking skills?
# 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)
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Knowing What to do/how to make a decision based upon available data.

50. What are the components of an assessment?
Having to use more than one pillow when sleeping
Preschool is cause and effect - school age begins to use logical thought process.
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Nurse