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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 nursing dx is best described as
Broncial (heard over trachea)
8.4
School age childen
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.

2. What is the difference between a nursing dx and a med dx?
Tricuspid - mitral and the aortic
Daily
Objective
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital

3. The fifth vital sign is
The result is accurate patient dB
Decreased arterial perfusion
Fast and deep respirations seen in patient's with acidosis
Pain

4. At What age do you begin to use decision making?
Hearing loss
Wandering
Adolescence
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve

5. What is the difference between hallucination and delirium?
EdFED- Q
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
8.4
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.

6. Subjective data could include
ID'ing status of exisiting problems and locating new issues
Disorganized thinking and altered LOC
Symptoms
Irregular respirations (fast/slow) often seen at end of life

7. An ongoing assessment is performed
Daily
Bacterial infection
Learning - memory and adaptation to stress
Nursing

8. In Which part of the nursing process will you find delegation?
Implementation
Decreased arterial perfusion
Vesicular (peripheral lung areas)
Hearing loss

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

10. What does CAM stand for
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
EdFED- Q
Confusion Assessment Method
Trend assessment (shift report)

11. When a patient has increased lymphocytes - this may indicate what?
Viral infection
Nurse
Symptoms
Paradoxical reaction

12. Blood passes through the heart valves In what order?
Tricuspid - mitral and the aortic
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
EdFED- Q
The medication will not affect the patient's breathing.

13. The purpose of an intitial assement serves to?
Pain
Assess over all health status and identify the problem
School age childen
Double check equip and patient

14. What are Cheyne Stokes?
Nurse
Trend assessment (shift report)
Irregular respirations (fast/slow) often seen at end of life
Pain

15. At patient that state their shoes are tighter at the end of the day may be experiencing
Knowing What to do/how to make a decision based upon available data.
Risk of falls increases
Edema
Sensory motor

16. Other factors that may indicate confusion using the CAM tool could be
Knowing What to do/how to make a decision based upon available data.
To ID the problem
Disorganized thinking and altered LOC
EdFED- Q

17. What would cause changes in congitive development later in life (middle adulthood)?
Defining a baseline of cognitive function - any changes or deviations from norm.
# of packs per day x # of years smoked
Trauma or illness
Snap - crackle - pops; velcro - bubble wrap

18. What is pain?
Initial assessment
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Implementation
A personal experience that does whatever the person in pain says it does

19. A potential adverse rx of chemically restraining a confused patient would be
Pt's with oxygenation and perfusion problems
Paradoxical reaction
Irregular respirations (fast/slow) often seen at end of life
Stroke volume x's heart rate

20. What is cognition?
Pt's underlying feelings
Decision assessment
Having to use more than one pillow when sleeping
The process of storing - learning - retrieving - and using info.

21. The order of air flow into the lungs is
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
School age childen
An 80 y/o patient that has emergency surgery
Wandering

22. The purpose of an initial assessment is
Secondary
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Inattention and acute increase/decrease in cognitive function
To ID the problem

23. Expiration sounds are heard longer than inspiration In What area?
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
Broncial (heard over trachea)
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Data collection - data validation - data organization - data analysis - and data reporting/recording.

24. Ongoing assessments are useful in

25. The path of blood from the lungs to the heart is
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Vesicular (peripheral lung areas)
Risk of falls increases
The medication will not affect the patient's breathing.

26. Data from the last 24/48 hours that included patterns would be a part of
Trauma or illness
Secondary soureces (family - friends)
Trend assessment (shift report)
Bacterial infection

27. What is a definition of a delusion?
A false - fixed belief that cannot be corrected through reasoning.
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Capillaries
Decision assessment

28. When a patient has increased neutrophils - this may indicate what?
Pain in legs assoc w walking
Interventions for which the nurse is accountable
Bacterial infection
Preschool is cause and effect - school age begins to use logical thought process.

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

30. Side effects of putting confused pts in restraints include
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
Initial assessment
Pt's underlying feelings

31. Where can you hear bronchovesicular breath sounds?
Implementation
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
The medication will not affect the patient's breathing.
Level of stress - risk for violence - anxiety level - patient unmet needs

32. Keeping patient's belongings - shoes - suitcases and street clothes - etc. out of view are helpful for preventing: wandering?
Pain
Wandering
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Pain

33. The path of blood from the heart to the lungs is
Capillaries
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Nurse
Eye hygeine - accomodating factors - what was the level of decline - how long has it been

34. What factors may indicate plural rub?
Pain
Pain on inspiration and expiration; superficial squeaking or grating
Upper airways
Secondary

35. What are the ABCDE's of pain management?
Immature immune system - structures close together lends to easy spreading from on area to another.
Ask - Believe - Choose - Deliver - Empower
Data collection - data validation - data organization - data analysis - and data reporting/recording.
The result is accurate patient dB

36. Kussamaul respirations describe

37. What is the nursing process?
Objective
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Have them do simple math problems
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.

38. An example of a primary source is
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
To ID the problem
The patient
Decision assessment

39. All body system data is not necessary which type of assessment
Focused
Trauma or illness
Secondary soureces (family - friends)
Defining a baseline of cognitive function - any changes or deviations from norm.

40. When performing an ongoing assessment for a patient with disturbed thinking the nurse should be sure to include
Defining a baseline of cognitive function - any changes or deviations from norm.
Level of stress - risk for violence - anxiety level - patient unmet needs
Abstract thinking
Wandering

41. The site where gas exchange occurs is
Fluid volume deficit related to poor intake
EdFED- Q
Capillaries
Communicate using hands and eyes.

42. Describe the purpose of a mental status exam
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Defining a baseline of cognitive function - any changes or deviations from norm.
# of packs per day x # of years smoked
Data collection - data validation - data organization - data analysis - and data reporting/recording.

43. An example of a nursing dx would be
Toddler
Trend assessment (shift report)
Fluid volume deficit related to poor intake
An 80 y/o patient that has emergency surgery

44. At What age do you begin to put thoughts into words?
Family - spouse - someone other than a healthcare worker - previous medical records.
Toddler
Level of stress - risk for violence - anxiety level - patient unmet needs
Secondary

45. Sleep deprivation can effect
Learning - memory and adaptation to stress
# of packs per day x # of years smoked
Capillaries
Bacterial infection

46. What is responsible for transporting O2 in the blood
Pt's underlying feelings
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Decreased sense of taste
Hemoglobin

47. Ageusia is
Double check equip and patient
Disorganized thinking and altered LOC
Loss of taste
Secondary soureces (family - friends)

48. QUESTT is a tool for What type of an assessment?
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Pain
Edema
Inattention and acute increase/decrease in cognitive function

49. Another term for a focused assessment is
Abstract thinking
The medication will not affect the patient's breathing.
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Ongoing assessment

50. What are Piaget's stages of cognitive development
Edema
Pain in legs assoc w walking
To simulate eating motions with the hands
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)