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Nursing Fundamentals 3

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Answer 50 questions in 15 minutes.
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Match each statement with the correct term.
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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. QUESTT is a tool for What type of an assessment?
Pain
Confusion Assessment Method
Objective
Toddler

2. When noticing a patient with dementia has stopped eating - the RN's first response is?
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Toddler
Broncial (heard over trachea)
To simulate eating motions with the hands

3. What is pain?
Snap - crackle - pops; velcro - bubble wrap
Implementation
Pain
A personal experience that does whatever the person in pain says it does

4. What do rhonchi sound like?
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Hemoglobin
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation

5. What is a chochlear implant?
Nursing dx
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Have them do simple math problems
Abstract thinking

6. What is responsible for transporting O2 in the blood
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Confusion Assessment Method
Level of stress - risk for violence - anxiety level - patient unmet needs
Hemoglobin

7. If an abnormal finding is revealed during assessment - the nurse should
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Implementation
Double check equip and patient
Initial assessment

8. Side effects of putting confused pts in restraints include
Bacterial infection
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Pt's underlying feelings
Objective

9. Ongoing assessments are useful in

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10. Where can you hear bronchovesicular breath sounds?
Immature immune system - structures close together lends to easy spreading from on area to another.
Non - opiod (ex: NSAID/acetominaphen)
Bacterial infection
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.

11. When using restraints in a confused patient
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Risk of falls increases
A false - fixed belief that cannot be corrected through reasoning.
Level of stress - risk for violence - anxiety level - patient unmet needs

12. At What age do you begin to put thoughts into words?
Toddler
Trend assessment (shift report)
Wandering
Nursing dx

13. Fluid volume deficit is a __________ dx
Snap - crackle - pops; velcro - bubble wrap
Nursing
Bacterial infection
Disorganized thinking and altered LOC

14. Name the 5 'W's' of assessing a change in LOC
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
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)
Pt's with oxygenation and perfusion problems

15. What are the ABCDE's of pain management?
Paradoxical reaction
Ask - Believe - Choose - Deliver - Empower
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Nursing dx

16. Data gathered via instrumention (pulse ox) is considered
EdFED- Q
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Edema
Objective

17. Once a medical dx has been made - who is accountable for the reporting s/s of complications?
Nurse
Broncial (heard over trachea)
No
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response

18. When a patient has increased lymphocytes - this may indicate what?
Interventions for which the nurse is accountable
Double check equip and patient
Viral infection
Abstract thinking

19. An example of a nursing dx would be
Preschool is cause and effect - school age begins to use logical thought process.
Fluid volume deficit related to poor intake
Adolescence
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts

20. Kussamaul respirations describe

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21. An example of a secondary source is
Wandering
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Family - spouse - someone other than a healthcare worker - previous medical records.
# of packs per day x # of years smoked

22. What are the components of a mental status exam that are not part of a regular assessment?
Pt's underlying feelings
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
Double check equip and patient

23. Factors that may reduce the efficacy of pulse oximetry include
Knowing What to do/how to make a decision based upon available data.
Hemoglobin
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -

24. What are Piaget's stages of cognitive development
Preschool is cause and effect - school age begins to use logical thought process.
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)
To simulate eating motions with the hands

25. A nursing dx is best described as
Pain
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
To simulate eating motions with the hands
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.

26. The site where gas exchange occurs is
Capillaries
To ID the problem
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
Fast and deep respirations seen in patient's with acidosis

27. What is cognition?
The process of storing - learning - retrieving - and using info.
Ongoing assessment
# of packs per day x # of years smoked
Decreased arterial perfusion

28. What do rales sound like?
Vesicular (peripheral lung areas)
Assess over all health status and identify the problem
Snap - crackle - pops; velcro - bubble wrap
Fluid volume deficit related to poor intake

29. Data from the last 24/48 hours that included patterns would be a part of
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Nurse
The process of storing - learning - retrieving - and using info.
Trend assessment (shift report)

30. 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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31. An infant is in which Paiget stage?
The patient
Sensory motor
Family - spouse - someone other than a healthcare worker - previous medical records.
Snap - crackle - pops; velcro - bubble wrap

32. What factors may indicate plural rub?
EdFED- Q
Broncial (heard over trachea)
Pain on inspiration and expiration; superficial squeaking or grating
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.

33. What are the components of an assessment?
Sensory motor
Secondary soureces (family - friends)
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Trend assessment (shift report)

34. Keeping patient's belongings - shoes - suitcases and street clothes - etc. out of view are helpful for preventing: wandering?
Disorganized thinking and altered LOC
ID'ing status of exisiting problems and locating new issues
Wandering
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.

35. Inspiration sounds are heard longer than expiration sounds In What area?
Tricuspid - mitral and the aortic
Paradoxical reaction
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Vesicular (peripheral lung areas)

36. A patient failing to answer questions or displaying a reluctance to participate in group or family activities may be experiencing
Hearing loss
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
Irregular respirations (fast/slow) often seen at end of life

37. What is the nursing process?
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Trauma or illness
Inattention and acute increase/decrease in cognitive function
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins

38. At patient that state their shoes are tighter at the end of the day may be experiencing
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
Ongoing assessment
A false - fixed belief that cannot be corrected through reasoning.
Edema

39. Nursing interventions should be based on who's theory?
Maslow
8.4
Symptoms
Daily

40. Data that is recorded for an immediate need (code blue or fall) would be included in
Decision assessment
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Serves to expedite dx and tx of actual and potential health problems
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation

41. Subjective data could include
The result is accurate patient dB
Edema
Symptoms
Pain in legs assoc w walking

42. What are Cheyne Stokes?
Irregular respirations (fast/slow) often seen at end of life
Pain in legs assoc w walking
Decision assessment
Pain

43. What is the correct approach when dealing with older adults?
Decision assessment
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Hemoglobin
School age childen

44. The order of air flow into the lungs is
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Medical
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
Pain

45. All body system data is not necessary which type of assessment
Implementation
Abstract thinking
Focused
Capillaries

46. What is intermittent claudication?
Risk of falls increases
Pain in legs assoc w walking
Bacterial infection
Loss of taste

47. In Which part of the nursing process will you find delegation?
Immature immune system - structures close together lends to easy spreading from on area to another.
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
Implementation
An 80 y/o patient that has emergency surgery

48. What is a definition of a delusion?
Sensory motor
Bacterial infection
A false - fixed belief that cannot be corrected through reasoning.
Having to use more than one pillow when sleeping

49. One way to test a person's cognitive ability and abstract thinking ability would be to
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
No
Have them do simple math problems
Knowing What to do/how to make a decision based upon available data.

50. Examples of personal information
Family - spouse - someone other than a healthcare worker - previous medical records.
Hygeine - DOB - work hx
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Wandering

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Nursing Fundamentals 3

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