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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. Hypogeusis is
Sensory motor
Decreased sense of taste
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
Upper airways

2. What is the difference between hallucination and delirium?
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Maslow
Medical
The medication will not affect the patient's breathing.

3. What are Cheyne Stokes?
Have them do simple math problems
Irregular respirations (fast/slow) often seen at end of life
Pain on inspiration and expiration; superficial squeaking or grating
Pain

4. ABG's would be an important lab value for What types of patient's?

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

6. What is cognition?
Immature immune system - structures close together lends to easy spreading from on area to another.
Ask - Believe - Choose - Deliver - Empower
Decreased arterial perfusion
The process of storing - learning - retrieving - and using info.

7. Data from the last 24/48 hours that included patterns would be a part of
Disorganized thinking and altered LOC
Trend assessment (shift report)
To ID the problem
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation

8. What is the purpose of the nursing process?
Serves to expedite dx and tx of actual and potential health problems
Snap - crackle - pops; velcro - bubble wrap
Risk of falls increases
Decreased sense of taste

9. Blood passes through the heart valves In what order?
Inattention and acute increase/decrease in cognitive function
Decreased arterial perfusion
Tricuspid - mitral and the aortic
Loss of taste

10. 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)
To ID the problem
Implementation
Upper airways

11. Ageusia is
Pain on inspiration and expiration; superficial squeaking or grating
Abstract thinking
Loss of taste
Nurse

12. Data that is recorded for an immediate need (code blue or fall) would be included in
Decision assessment
EdFED- Q
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Surgically implanted device for deaf or hard or hearing - also called bionic ear.

13. What would cause changes in congitive development later in life (middle adulthood)?
Trauma or illness
EdFED- Q
Tricuspid - mitral and the aortic
Initial assessment

14. 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 -
Adolescence
Double check equip and patient
Ongoing assessment

15. The assessment that includes the patient's overhall health status
Trauma or illness
Inattention and acute increase/decrease in cognitive function
Vesicular (peripheral lung areas)
Initial assessment

16. Kussamaul respirations describe

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17. An infant is in which Paiget stage?
Sensory motor
Focused
Knowing What to do/how to make a decision based upon available data.
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances

18. Acceptable sources of assessment data when evaluating a confused patient would be
To simulate eating motions with the hands
Loss of taste
Secondary soureces (family - friends)
Sensory motor

19. Which patient would be most likely to experience sensory overload?
An 80 y/o patient that has emergency surgery
Irregular respirations (fast/slow) often seen at end of life
Pain in legs assoc w walking
Adolescence

20. An ongoing assessment is performed
Daily
Hearing loss
Decreased arterial perfusion
Pain

21. When performing an interview with a patient with vision loss - select the correct questions for obtaining an accurate vision history
Communicate using hands and eyes.
Bacterial infection
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Learning - memory and adaptation to stress

22. Fluid volume deficit is a __________ dx
Assess over all health status and identify the problem
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
Toddler
Nursing

23. When speaking with a patient with moderate hearing loss the RN should
Communicate using hands and eyes.
Nursing
Secondary
Adolescence

24. What is intermittent claudication?
Family - spouse - someone other than a healthcare worker - previous medical records.
Pain in legs assoc w walking
EdFED- Q
Focused

25. Examples of personal information
Pt's underlying feelings
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
Hygeine - DOB - work hx
8.4

26. Name the 5 'W's' of assessing a change in LOC
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)
Knowing What to do/how to make a decision based upon available data.
Broncial (heard over trachea)

27. What does CAM stand for
Confusion Assessment Method
Decision assessment
Loss of taste
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.

28. Nursing dx provides basis of
Interventions for which the nurse is accountable
Preschool is cause and effect - school age begins to use logical thought process.
Paradoxical reaction
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.

29. What do rales sound like?
Immature immune system - structures close together lends to easy spreading from on area to another.
Snap - crackle - pops; velcro - bubble wrap
Vesicular (peripheral lung areas)
Focused

30. Ongoing assessments are useful in

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31. When a patient has increased lymphocytes - this may indicate what?
Hearing loss
Medical
Viral infection
Data collection - data validation - data organization - data analysis - and data reporting/recording.

32. What factors may indicate plural rub?
Learning - memory and adaptation to stress
Capillaries
Pt's with oxygenation and perfusion problems
Pain on inspiration and expiration; superficial squeaking or grating

33. Side effects of putting confused pts in restraints include
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Paradoxical reaction
Medical
8.4

34. Sleep deprivation can effect
The medication will not affect the patient's breathing.
Ongoing assessment
Learning - memory and adaptation to stress
Interventions for which the nurse is accountable

35. Subjective data could include
Pain in legs assoc w walking
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
The result is accurate patient dB
Symptoms

36. What is a chochlear implant?
Nursing dx
To simulate eating motions with the hands
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Pain

37. Data gathered via instrumention (pulse ox) is considered
Nursing dx
Implementation
Objective
Snap - crackle - pops; velcro - bubble wrap

38. Data validation assures
The result is accurate patient dB
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Learning - memory and adaptation to stress
Pt's with oxygenation and perfusion problems

39. At patient that state their shoes are tighter at the end of the day may be experiencing
Toddler
Learning - memory and adaptation to stress
ID'ing status of exisiting problems and locating new issues
Edema

40. A potential adverse rx of chemically restraining a confused patient would be
Vesicular (peripheral lung areas)
# of packs per day x # of years smoked
Paradoxical reaction
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli

41. The site where gas exchange occurs is
Capillaries
Pain
No
Trend assessment (shift report)

42. At What age do you begin to use logical thought process?
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
School age childen
Irregular respirations (fast/slow) often seen at end of life
Viral infection

43. What is a definition of a delusion?
An 80 y/o patient that has emergency surgery
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
A false - fixed belief that cannot be corrected through reasoning.
To ID the problem

44. An example of a secondary source is
Family - spouse - someone other than a healthcare worker - previous medical records.
The medication will not affect the patient's breathing.
Decreased sense of taste
Confusion Assessment Method

45. What is responsible for transporting O2 in the blood
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Nursing dx
Hemoglobin

46. What is a component of the cognitive part of critical thinking skills?
Risk of falls increases
Abstract thinking
Knowing What to do/how to make a decision based upon available data.
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.

47. If an abnormal finding is revealed during assessment - the nurse should
Confusion Assessment Method
Double check equip and patient
Knowing What to do/how to make a decision based upon available data.
Preschool is cause and effect - school age begins to use logical thought process.

48. When a patient has increased neutrophils - this may indicate what?
Have them do simple math problems
Secondary
Bacterial infection
Tricuspid - mitral and the aortic

49. Asking a patient what would you do if there is a fire in the wastebasket - is a way to assess their
Family - spouse - someone other than a healthcare worker - previous medical records.
Paradoxical reaction
An 80 y/o patient that has emergency surgery
Abstract thinking

50. What scale is used to determine eating and feeding issues in adults with confusion
Learning - memory and adaptation to stress
EdFED- Q
A false - fixed belief that cannot be corrected through reasoning.
Trend assessment (shift report)