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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. What is the formula for determining pack years?
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Daily
# of packs per day x # of years smoked
Risk of falls increases

2. Ongoing assessments are useful in

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3. 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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4. Which patient would be most likely to experience sensory overload?
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Adolescence
An 80 y/o patient that has emergency surgery
Hemoglobin

5. An infant is in which Paiget stage?
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Sensory motor
To simulate eating motions with the hands
Pt's with oxygenation and perfusion problems

6. What is the difference between hallucination and delirium?
The patient
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Inattention and acute increase/decrease in cognitive function
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.

7. Nursing dx provides basis of
Interventions for which the nurse is accountable
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Defining a baseline of cognitive function - any changes or deviations from norm.
Abstract thinking

8. What is cognition?
Learning - memory and adaptation to stress
Viral infection
Serves to expedite dx and tx of actual and potential health problems
The process of storing - learning - retrieving - and using info.

9. The path of blood from the heart to the lungs is
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Level of stress - risk for violence - anxiety level - patient unmet needs
Interventions for which the nurse is accountable
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.

10. Kussamaul respirations describe

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11. What is responsible for transporting O2 in the blood
Hemoglobin
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Initial assessment
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.

12. What is intermittent claudication?
Ongoing assessment
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Pain in legs assoc w walking
Immature immune system - structures close together lends to easy spreading from on area to another.

13. At What age do you begin to use logical thought process?
An 80 y/o patient that has emergency surgery
Preschool is cause and effect - school age begins to use logical thought process.
School age childen
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.

14. What is the correct approach when dealing with older adults?
The process of storing - learning - retrieving - and using info.
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
No
Confusion Assessment Method

15. What do rales sound like?
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Decreased arterial perfusion
Snap - crackle - pops; velcro - bubble wrap

16. If an abnormal finding is revealed during assessment - the nurse should
Double check equip and patient
Stroke volume x's heart rate
Level of stress - risk for violence - anxiety level - patient unmet needs
Have them do simple math problems

17. Data gathered via instrumention (pulse ox) is considered
Toddler
Implementation
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Objective

18. Types of hearing loss include
Having to use more than one pillow when sleeping
Symptoms
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
School age childen

19. Why are young children at greater risk for respiratory infection?
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
Pt's with oxygenation and perfusion problems
Wandering
Immature immune system - structures close together lends to easy spreading from on area to another.

20. All body system data is not necessary which type of assessment
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.
Pt's with oxygenation and perfusion problems
Focused

21. The path of blood from the lungs to the heart is
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Broncial (heard over trachea)
Hygeine - DOB - work hx
School age childen

22. Expiration sounds are heard longer than inspiration In What area?
Decreased sense of taste
Initial assessment
Broncial (heard over trachea)
Confusion Assessment Method

23. When a patient has increased lymphocytes - this may indicate what?
Viral infection
Vesicular (peripheral lung areas)
Secondary
To simulate eating motions with the hands

24. What scale is used to determine eating and feeding issues in adults with confusion
Ask - Believe - Choose - Deliver - Empower
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Capillaries
EdFED- Q

25. When noticing a patient with dementia has stopped eating - the RN's first response is?
Objective
To simulate eating motions with the hands
Capillaries
Having to use more than one pillow when sleeping

26. What does CAM stand for
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Pt's underlying feelings
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Confusion Assessment Method

27. Are changes in vital signs a reliable indicator of chronic pain?
# of packs per day x # of years smoked
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
No
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins

28. What is the difference between a nursing dx and a med dx?
Upper airways
To simulate eating motions with the hands
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Risk of falls increases

29. Where can wheezes best be heard?
Upper airways
Paradoxical reaction
Pain
Trend assessment (shift report)

30. At What age do you begin to put thoughts into words?
Abstract thinking
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Toddler
Focused

31. A potential adverse rx of chemically restraining a confused patient would be
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Paradoxical reaction
Trend assessment (shift report)
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins

32. An ongoing assessment is performed
Having to use more than one pillow when sleeping
Pt's underlying feelings
Medical
Daily

33. When a patient has increased neutrophils - this may indicate what?
Communicate using hands and eyes.
Viral infection
Confusion Assessment Method
Bacterial infection

34. At What age do you begin to use decision making?
Defining a baseline of cognitive function - any changes or deviations from norm.
Secondary
Adolescence
Pain on inspiration and expiration; superficial squeaking or grating

35. Inspiration sounds are heard longer than expiration sounds In What area?
Capillaries
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
Family - spouse - someone other than a healthcare worker - previous medical records.
Vesicular (peripheral lung areas)

36. What is a definition of a delusion?
The patient
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Data collection - data validation - data organization - data analysis - and data reporting/recording.
A false - fixed belief that cannot be corrected through reasoning.

37. A patient that is easily fatigued may have a HgB lab value of?
Secondary
Fast and deep respirations seen in patient's with acidosis
8.4
Implementation

38. What is the formula for cardiac output?

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39. What is pain?
A personal experience that does whatever the person in pain says it does
Toddler
Stroke volume x's heart rate
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli

40. QUESTT is a tool for What type of an assessment?
School age childen
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Daily
Pain

41. Fluid volume deficit is a __________ dx
Confusion Assessment Method
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Wandering
Nursing

42. What is the purpose of the nursing process?
Tricuspid - mitral and the aortic
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Learning - memory and adaptation to stress
Serves to expedite dx and tx of actual and potential health problems

43. What would cause changes in congitive development later in life (middle adulthood)?
Trauma or illness
Bacterial infection
Abstract thinking
Nursing

44. What is a component of the cognitive part of critical thinking skills?
Knowing What to do/how to make a decision based upon available data.
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
Nursing

45. A patient failing to answer questions or displaying a reluctance to participate in group or family activities may be experiencing
Paradoxical reaction
The medication will not affect the patient's breathing.
Adolescence
Hearing loss

46. Would a nursing dx be part of the primary or secondary dx?
Broncial (heard over trachea)
Hygeine - DOB - work hx
Tricuspid - mitral and the aortic
Secondary

47. When performing an ongoing assessment for a patient with disturbed thinking the nurse should be sure to include
Risk of falls increases
Broncial (heard over trachea)
Level of stress - risk for violence - anxiety level - patient unmet needs
Toddler

48. At patient that state their shoes are tighter at the end of the day may be experiencing
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Edema
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Pain

49. 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
Implementation
Ongoing assessment
Interventions for which the nurse is accountable

50. The purpose of an intitial assement serves to?
Assess over all health status and identify the problem
Fluid volume deficit related to poor intake
Non - opiod (ex: NSAID/acetominaphen)
Toddler

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Nursing Fundamentals 3

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