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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. Asking a patient what would you do if there is a fire in the wastebasket - is a way to assess their
Hygeine - DOB - work hx
Paradoxical reaction
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
Abstract thinking

2. What is the formula for cardiac output?

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3. Types of hearing loss include
Secondary soureces (family - friends)
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Vesicular (peripheral lung areas)

4. Acceptable sources of assessment data when evaluating a confused patient would be
Hemoglobin
Secondary soureces (family - friends)
Have them do simple math problems
Abstract thinking

5. Sleep deprivation can effect
Learning - memory and adaptation to stress
Double check equip and patient
A false - fixed belief that cannot be corrected through reasoning.
School age childen

6. An ongoing assessment is performed
8.4
Decreased arterial perfusion
Vesicular (peripheral lung areas)
Daily

7. When using restraints in a confused patient
Interventions for which the nurse is accountable
Bacterial infection
Upper airways
Risk of falls increases

8. What is a definition of a delusion?
A personal experience that does whatever the person in pain says it does
A false - fixed belief that cannot be corrected through reasoning.
Maslow
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response

9. The purpose of an initial assessment is
Assess over all health status and identify the problem
Knowing What to do/how to make a decision based upon available data.
# of packs per day x # of years smoked
To ID the problem

10. Once a medical dx has been made - who is accountable for the reporting s/s of complications?
Nurse
Stroke volume x's heart rate
The result is accurate patient dB
Edema

11. What is the nursing process?
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
A false - fixed belief that cannot be corrected through reasoning.
Family - spouse - someone other than a healthcare worker - previous medical records.
Hearing loss

12. The basis for a plan of care comes for which stage of the nursing process?
Interventions for which the nurse is accountable
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Nursing dx
Stroke volume x's heart rate

13. What is the difference between hallucination and delirium?
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Fast and deep respirations seen in patient's with acidosis
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Irregular respirations (fast/slow) often seen at end of life

14. What are Cheyne Stokes?
Trauma or illness
Family - spouse - someone other than a healthcare worker - previous medical records.
Irregular respirations (fast/slow) often seen at end of life
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.

15. What is cognition?
Inattention and acute increase/decrease in cognitive function
Capillaries
The process of storing - learning - retrieving - and using info.
Tricuspid - mitral and the aortic

16. Ageusia is
Toddler
Capillaries
Loss of taste
Preschool is cause and effect - school age begins to use logical thought process.

17. When a patient has increased neutrophils - this may indicate what?
Bacterial infection
Defining a baseline of cognitive function - any changes or deviations from norm.
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Broncial (heard over trachea)

18. 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
Capillaries
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins

19. Name the 5 'W's' of assessing a change in LOC
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Inattention and acute increase/decrease in cognitive function
Serves to expedite dx and tx of actual and potential health problems
8.4

20. What is intermittent claudication?
Pain in legs assoc w walking
Symptoms
A personal experience that does whatever the person in pain says it does
# of packs per day x # of years smoked

21. What would cause changes in congitive development later in life (middle adulthood)?
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Symptoms
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Trauma or illness

22. At patient that state their shoes are tighter at the end of the day may be experiencing
# of packs per day x # of years smoked
Fluid volume deficit related to poor intake
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Edema

23. Side effects of putting confused pts in restraints include
Defining a baseline of cognitive function - any changes or deviations from norm.
Hygeine - DOB - work hx
Communicate using hands and eyes.
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy

24. What are the steps of the nursing process?
Nursing dx
To ID the problem
Defining a baseline of cognitive function - any changes or deviations from norm.
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation

25. At What age do you begin to put thoughts into words?
Pt's underlying feelings
Toddler
To simulate eating motions with the hands
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve

26. The assessment that includes the patient's overhall health status
Disorganized thinking and altered LOC
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
To simulate eating motions with the hands
Initial assessment

27. One way to test a person's cognitive ability and abstract thinking ability would be to
Edema
School age childen
Have them do simple math problems
Nursing dx

28. When performing an interview with a patient with vision loss - select the correct questions for obtaining an accurate vision history
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
A false - fixed belief that cannot be corrected through reasoning.
School age childen
Having to use more than one pillow when sleeping

29. QUESTT is a tool for What type of an assessment?
A false - fixed belief that cannot be corrected through reasoning.
The result is accurate patient dB
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Pain

30. What is a chochlear implant?
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Edema
Nursing
Surgically implanted device for deaf or hard or hearing - also called bionic ear.

31. Factors that may reduce the efficacy of pulse oximetry include
EdFED- Q
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Focused
Sensory motor

32. An example of a secondary source is
Abstract thinking
Family - spouse - someone other than a healthcare worker - previous medical records.
Irregular respirations (fast/slow) often seen at end of life
Learning - memory and adaptation to stress

33. Kussamaul respirations describe

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34. Another term for a focused assessment is
Ongoing assessment
Vesicular (peripheral lung areas)
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Decreased arterial perfusion

35. What is the correct approach when dealing with older adults?
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Implementation
Learning - memory and adaptation to stress

36. If an abnormal finding is revealed during assessment - the nurse should
Fluid volume deficit related to poor intake
EdFED- Q
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Double check equip and patient

37. Where can wheezes best be heard?
Hemoglobin
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)
Upper airways

38. 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.
Pain
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
Eye hygeine - accomodating factors - what was the level of decline - how long has it been

39. A patient failing to answer questions or displaying a reluctance to participate in group or family activities may be experiencing
Decision assessment
Pt's with oxygenation and perfusion problems
Hemoglobin
Hearing loss

40. When noticing a patient with dementia has stopped eating - the RN's first response is?
Wandering
To simulate eating motions with the hands
Sensory motor
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.

41. Nursing dx provides basis of
Ongoing assessment
Interventions for which the nurse is accountable
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)

42. 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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43. At What age do you begin to use logical thought process?
School age childen
Double check equip and patient
Abstract thinking
Decision assessment

44. Which patient would be most likely to experience sensory overload?
Decision assessment
Preschool is cause and effect - school age begins to use logical thought process.
An 80 y/o patient that has emergency surgery
Snap - crackle - pops; velcro - bubble wrap

45. What is the cognitive difference between a preschooler and schoolage child?
To simulate eating motions with the hands
Hemoglobin
Preschool is cause and effect - school age begins to use logical thought process.
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli

46. A patient that is easily fatigued may have a HgB lab value of?
Pain
Upper airways
8.4
Non - opiod (ex: NSAID/acetominaphen)

47. What is pain?
Upper airways
Learning - memory and adaptation to stress
EdFED- Q
A personal experience that does whatever the person in pain says it does

48. What is the purpose of the nursing process?
Decision assessment
The process of storing - learning - retrieving - and using info.
Serves to expedite dx and tx of actual and potential health problems
To simulate eating motions with the hands

49. What do rhonchi sound like?
Viral infection
Tricuspid - mitral and the aortic
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Nurse

50. Intermittent claudication is caused by?
The medication will not affect the patient's breathing.
School age childen
Objective
Decreased arterial perfusion