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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
Paradoxical reaction
A personal experience that does whatever the person in pain says it does
Hearing loss
Nurse

2. What is the difference between hallucination and delirium?
School age childen
Ongoing assessment
Risk of falls increases
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.

3. Data validation assures
The result is accurate patient dB
Vesicular (peripheral lung areas)
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
The patient

4. Ageusia is
Loss of taste
Fluid volume deficit related to poor intake
Focused
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli

5. An example of a primary source is
The patient
Defining a baseline of cognitive function - any changes or deviations from norm.
To simulate eating motions with the hands
Pt's with oxygenation and perfusion problems

6. Two indicators that are REQUIRED for classification via the CAM tool include
Trend assessment (shift report)
Ongoing assessment
Inattention and acute increase/decrease in cognitive function
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -

7. What are Piaget's stages of cognitive development
Decision assessment
Decreased sense of taste
The process of storing - learning - retrieving - and using info.
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)

8. Once a medical dx has been made - who is accountable for the reporting s/s of complications?
Have them do simple math problems
Nurse
Daily
Pain

9. Name the 5 'W's' of assessing a change in LOC
Sensory motor
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
Have them do simple math problems

10. What do rhonchi sound like?
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Nursing
Trauma or illness
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts

11. Expiration sounds are heard longer than inspiration In What area?
Learning - memory and adaptation to stress
Broncial (heard over trachea)
# of packs per day x # of years smoked
Paradoxical reaction

12. A patient that is easily fatigued may have a HgB lab value of?
8.4
Pt's with oxygenation and perfusion problems
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Pain on inspiration and expiration; superficial squeaking or grating

13. What are the steps of the nursing process?
Tricuspid - mitral and the aortic
Symptoms
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Paradoxical reaction

14. What are the components of an assessment?
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Pain
Adolescence
To ID the problem

15. The basis for a plan of care comes for which stage of the nursing process?
Trend assessment (shift report)
Edema
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Nursing dx

16. The purpose of an intitial assement serves to?
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
Fluid volume deficit related to poor intake
Objective

17. Side effects of putting confused pts in restraints include
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Broncial (heard over trachea)
Fast and deep respirations seen in patient's with acidosis
Nurse

18. What does CAM stand for
Pain
Confusion Assessment Method
Ask - Believe - Choose - Deliver - Empower
# of packs per day x # of years smoked

19. 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
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Disorganized thinking and altered LOC

20. If an abnormal finding is revealed during assessment - the nurse should
Adolescence
Pain
Double check equip and patient
Toddler

21. When a patient has increased neutrophils - this may indicate what?
Pt's underlying feelings
Bacterial infection
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
The patient

22. What factors may indicate plural rub?
Immature immune system - structures close together lends to easy spreading from on area to another.
Knowing What to do/how to make a decision based upon available data.
Loss of taste
Pain on inspiration and expiration; superficial squeaking or grating

23. A nursing dx is best described as
EdFED- Q
Defining a baseline of cognitive function - any changes or deviations from norm.
Risk of falls increases
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.

24. A patient failing to answer questions or displaying a reluctance to participate in group or family activities may be experiencing
Hearing loss
The patient
Stroke volume x's heart rate
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy

25. What is the correct approach when dealing with older adults?
Non - opiod (ex: NSAID/acetominaphen)
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Paradoxical reaction

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

27. What is intermittent claudication?
Medical
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Pain in legs assoc w walking
Irregular respirations (fast/slow) often seen at end of life

28. What is responsible for transporting O2 in the blood
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Hemoglobin
Irregular respirations (fast/slow) often seen at end of life
An 80 y/o patient that has emergency surgery

29. One way to test a person's cognitive ability and abstract thinking ability would be to
Have them do simple math problems
8.4
Pain
Sensory motor

30. 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)
A false - fixed belief that cannot be corrected through reasoning.
Hygeine - DOB - work hx
Upper airways

31. What are the ABCDE's of pain management?
Trauma or illness
Pain on inspiration and expiration; superficial squeaking or grating
Paradoxical reaction
Ask - Believe - Choose - Deliver - Empower

32. Data gathered via instrumention (pulse ox) is considered
Pt's with oxygenation and perfusion problems
Objective
Communicate using hands and eyes.
Stroke volume x's heart rate

33. Where can you hear bronchovesicular breath sounds?
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Decreased arterial perfusion
The patient

34. An example of a secondary source is
Immature immune system - structures close together lends to easy spreading from on area to another.
Family - spouse - someone other than a healthcare worker - previous medical records.
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Stroke volume x's heart rate

35. What is the formula for determining pack years?
Trend assessment (shift report)
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
# of packs per day x # of years smoked
Hearing loss

36. The site where gas exchange occurs is
Trauma or illness
Ongoing assessment
Capillaries
Nurse

37. Diabetes is a _________ dx
The patient
Medical
Nursing
Pt's underlying feelings

38. An infant is in which Paiget stage?
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Ongoing assessment
Sensory motor
The process of storing - learning - retrieving - and using info.

39. When performing an ongoing assessment for a patient with disturbed thinking the nurse should be sure to include
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
The result is accurate patient dB
Daily
Level of stress - risk for violence - anxiety level - patient unmet needs

40. What is the difference between a nursing dx and a med dx?
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Interventions for which the nurse is accountable

41. The path of blood from the heart to the lungs is
Pain in legs assoc w walking
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Secondary

42. If patient reports pain of 3 on scale of 0-10 - What is the appropriate class of pain reliever?
The process of storing - learning - retrieving - and using info.
Non - opiod (ex: NSAID/acetominaphen)
Initial assessment
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response

43. 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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44. At What age do you begin to put thoughts into words?
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Bacterial infection
Toddler
The process of storing - learning - retrieving - and using info.

45. In Which part of the nursing process will you find delegation?
Edema
Focused
Implementation
Stroke volume x's heart rate

46. What is the purpose of the nursing process?
An 80 y/o patient that has emergency surgery
Fast and deep respirations seen in patient's with acidosis
Serves to expedite dx and tx of actual and potential health problems
Eye hygeine - accomodating factors - what was the level of decline - how long has it been

47. What are Cheyne Stokes?
Irregular respirations (fast/slow) often seen at end of life
Risk of falls increases
Abstract thinking
Stroke volume x's heart rate

48. When using restraints in a confused patient
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
Risk of falls increases
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Confusion Assessment Method

49. Blood passes through the heart valves In what order?
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Hygeine - DOB - work hx
Snap - crackle - pops; velcro - bubble wrap
Tricuspid - mitral and the aortic

50. Why are young children at greater risk for respiratory infection?
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Immature immune system - structures close together lends to easy spreading from on area to another.
Decreased arterial perfusion
ID'ing status of exisiting problems and locating new issues