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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 pain?
A personal experience that does whatever the person in pain says it does
Communicate using hands and eyes.
Vesicular (peripheral lung areas)
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.

2. Where can wheezes best be heard?
Bacterial infection
Upper airways
Family - spouse - someone other than a healthcare worker - previous medical records.
Knowing What to do/how to make a decision based upon available data.

3. In Which part of the nursing process will you find delegation?
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
Implementation
A personal experience that does whatever the person in pain says it does
Sensory motor

4. Subjective data could include
Pain in legs assoc w walking
# of packs per day x # of years smoked
Symptoms
Edema

5. 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)
Trend assessment (shift report)
Risk of falls increases
The patient

6. If patient reports pain of 3 on scale of 0-10 - What is the appropriate class of pain reliever?
Disorganized thinking and altered LOC
Trauma or illness
Assess over all health status and identify the problem
Non - opiod (ex: NSAID/acetominaphen)

7. What is a definition of a delusion?
A false - fixed belief that cannot be corrected through reasoning.
Sensory motor
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Nursing

8. A nursing dx is best described as
Wandering
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.

9. One way to test a person's cognitive ability and abstract thinking ability would be to
Snap - crackle - pops; velcro - bubble wrap
Have them do simple math problems
No
# of packs per day x # of years smoked

10. Expiration sounds are heard longer than inspiration In What area?
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Broncial (heard over trachea)
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
# of packs per day x # of years smoked

11. When noticing a patient with dementia has stopped eating - the RN's first response is?
Decreased sense of taste
To simulate eating motions with the hands
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Nurse

12. Which patient would be most likely to experience sensory overload?
An 80 y/o patient that has emergency surgery
Nursing dx
Learning - memory and adaptation to stress
A false - fixed belief that cannot be corrected through reasoning.

13. The path of blood from the heart to the lungs is
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)
Stroke volume x's heart rate
Daily

14. What is cognition?
The process of storing - learning - retrieving - and using info.
Edema
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Level of stress - risk for violence - anxiety level - patient unmet needs

15. An infant is in which Paiget stage?
The patient
Initial assessment
Sensory motor
Decreased sense of taste

16. What is the nursing process?
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
School age childen
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
Tricuspid - mitral and the aortic

17. Other factors that may indicate confusion using the CAM tool could be
Bacterial infection
Immature immune system - structures close together lends to easy spreading from on area to another.
Pain on inspiration and expiration; superficial squeaking or grating
Disorganized thinking and altered LOC

18. Factors that may reduce the efficacy of pulse oximetry include
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
Pain in legs assoc w walking
The medication will not affect the patient's breathing.
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -

19. An ongoing assessment is performed
To ID the problem
Daily
Have them do simple math problems
A personal experience that does whatever the person in pain says it does

20. Diabetes is a _________ dx
Confusion Assessment Method
Medical
Pt's with oxygenation and perfusion problems
Abstract thinking

21. At patient that state their shoes are tighter at the end of the day may be experiencing
Adolescence
Ask - Believe - Choose - Deliver - Empower
Edema
Hearing loss

22. Name the 5 'W's' of assessing a change in LOC
Edema
Hemoglobin
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Preschool is cause and effect - school age begins to use logical thought process.

23. The basis for a plan of care comes for which stage of the nursing process?
Nursing dx
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Pain in legs assoc w walking
Edema

24. Describe the purpose of a mental status exam
A personal experience that does whatever the person in pain says it does
Maslow
Hygeine - DOB - work hx
Defining a baseline of cognitive function - any changes or deviations from norm.

25. A patient that is dying is on morphine. The family is concerned the prs breathing will stop. What is the correct RN response?

26. What would cause changes in congitive development later in life (middle adulthood)?
Loss of taste
Trauma or illness
Inattention and acute increase/decrease in cognitive function
Irregular respirations (fast/slow) often seen at end of life

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

28. 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
Snap - crackle - pops; velcro - bubble wrap
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy

29. When performing an interview with a patient with vision loss - select the correct questions for obtaining an accurate vision history
Pt's underlying feelings
The process of storing - learning - retrieving - and using info.
The patient
Eye hygeine - accomodating factors - what was the level of decline - how long has it been

30. Two indicators that are REQUIRED for classification via the CAM tool include
No
An 80 y/o patient that has emergency surgery
Tricuspid - mitral and the aortic
Inattention and acute increase/decrease in cognitive function

31. The order of air flow into the lungs is
Fast and deep respirations seen in patient's with acidosis
Pain
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
Pain in legs assoc w walking

32. An example of a nursing dx would be
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Nurse
Initial assessment
Fluid volume deficit related to poor intake

33. Data validation assures
The result is accurate patient dB
A false - fixed belief that cannot be corrected through reasoning.
8.4
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.

34. Nursing dx provides basis of
Interventions for which the nurse is accountable
Edema
Level of stress - risk for violence - anxiety level - patient unmet needs
Adolescence

35. Inspiration sounds are heard longer than expiration sounds In What area?
Ongoing assessment
Inattention and acute increase/decrease in cognitive function
Pain on inspiration and expiration; superficial squeaking or grating
Vesicular (peripheral lung areas)

36. A potential adverse rx of chemically restraining a confused patient would be
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Fluid volume deficit related to poor intake
Decreased sense of taste
Paradoxical reaction

37. What are Cheyne Stokes?
# of packs per day x # of years smoked
Broncial (heard over trachea)
Irregular respirations (fast/slow) often seen at end of life
ID'ing status of exisiting problems and locating new issues

38. What is the formula for cardiac output?

39. What is the formula for determining pack years?
Objective
Disorganized thinking and altered LOC
# of packs per day x # of years smoked
Pt's with oxygenation and perfusion problems

40. Orthopnea is described as?
ID'ing status of exisiting problems and locating new issues
Having to use more than one pillow when sleeping
Decreased sense of taste
Paradoxical reaction

41. An example of a secondary source is
Irregular respirations (fast/slow) often seen at end of life
Broncial (heard over trachea)
The process of storing - learning - retrieving - and using info.
Family - spouse - someone other than a healthcare worker - previous medical records.

42. What factors may indicate plural rub?
Ongoing assessment
Secondary
To ID the problem
Pain on inspiration and expiration; superficial squeaking or grating

43. When a patient has increased lymphocytes - this may indicate what?
Abstract thinking
Implementation
Double check equip and patient
Viral infection

44. When a patient has increased neutrophils - this may indicate what?
Level of stress - risk for violence - anxiety level - patient unmet needs
Bacterial infection
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
8.4

45. Would a nursing dx be part of the primary or secondary dx?
Disorganized thinking and altered LOC
Secondary soureces (family - friends)
8.4
Secondary

46. Acceptable sources of assessment data when evaluating a confused patient would be
Nursing
Secondary soureces (family - friends)
Have them do simple math problems
Confusion Assessment Method

47. What does CAM stand for
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
Confusion Assessment Method
Serves to expedite dx and tx of actual and potential health problems
Hemoglobin

48. Kussamaul respirations describe

49. Where can you hear bronchovesicular breath sounds?
Hemoglobin
Implementation
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
8.4

50. The site where gas exchange occurs is
Family - spouse - someone other than a healthcare worker - previous medical records.
Capillaries
EdFED- Q
Decreased arterial perfusion