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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. Another term for a focused assessment is
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Implementation
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Ongoing assessment

2. Expiration sounds are heard longer than inspiration In What area?
The process of storing - learning - retrieving - and using info.
Broncial (heard over trachea)
Fast and deep respirations seen in patient's with acidosis
Interventions for which the nurse is accountable

3. What would cause changes in congitive development later in life (middle adulthood)?
Trauma or illness
Nursing dx
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Secondary

4. What are Cheyne Stokes?
The result is accurate patient dB
Ongoing assessment
No
Irregular respirations (fast/slow) often seen at end of life

5. Which patient would be most likely to experience sensory overload?
Medical
An 80 y/o patient that has emergency surgery
Secondary soureces (family - friends)
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response

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

7. Orthopnea is described as?
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
8.4
Tricuspid - mitral and the aortic
Having to use more than one pillow when sleeping

8. Nursing interventions should be based on who's theory?
A personal experience that does whatever the person in pain says it does
Maslow
Communicate using hands and eyes.
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts

9. What is the difference between a nursing dx and a med dx?
Communicate using hands and eyes.
Pain
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Nurse

10. What is a component of the cognitive part of critical thinking skills?
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Paradoxical reaction
Knowing What to do/how to make a decision based upon available data.
The process of storing - learning - retrieving - and using info.

11. What are the ABCDE's of pain management?
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
Ask - Believe - Choose - Deliver - Empower
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Maslow

12. Data validation assures
Assess over all health status and identify the problem
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
The result is accurate patient dB
The medication will not affect the patient's breathing.

13. The assessment that includes the patient's overhall health status
Sensory motor
Implementation
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
Initial assessment

14. Describe the purpose of a mental status exam
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
The result is accurate patient dB
Snap - crackle - pops; velcro - bubble wrap
Defining a baseline of cognitive function - any changes or deviations from norm.

15. A patient failing to answer questions or displaying a reluctance to participate in group or family activities may be experiencing
Sensory motor
8.4
Interventions for which the nurse is accountable
Hearing loss

16. Hypogeusis is
Assess over all health status and identify the problem
Decreased sense of taste
Knowing What to do/how to make a decision based upon available data.
Paradoxical reaction

17. The basis for a plan of care comes for which stage of the nursing process?
Vesicular (peripheral lung areas)
Decreased sense of taste
Nursing dx
To ID the problem

18. What is the purpose of the nursing process?
Pain
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Daily
Serves to expedite dx and tx of actual and potential health problems

19. Fluid volume deficit is a __________ dx
Assess over all health status and identify the problem
Knowing What to do/how to make a decision based upon available data.
Symptoms
Nursing

20. When a patient has increased neutrophils - this may indicate what?
Non - opiod (ex: NSAID/acetominaphen)
Bacterial infection
Abstract thinking
Knowing What to do/how to make a decision based upon available data.

21. What is cognition?
School age childen
The process of storing - learning - retrieving - and using info.
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Ask - Believe - Choose - Deliver - Empower

22. The purpose of an initial assessment is
The medication will not affect the patient's breathing.
To ID the problem
# of packs per day x # of years smoked
Vesicular (peripheral lung areas)

23. 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 -
To ID the problem
Preschool is cause and effect - school age begins to use logical thought process.
Vesicular (peripheral lung areas)

24. Ongoing assessments are useful in

25. If an abnormal finding is revealed during assessment - the nurse should
Focused
Adolescence
Double check equip and patient
Decreased sense of taste

26. Would a nursing dx be part of the primary or secondary dx?
Secondary
Decreased sense of taste
Secondary soureces (family - friends)
8.4

27. At What age do you begin to use decision making?
Decreased sense of taste
Edema
A personal experience that does whatever the person in pain says it does
Adolescence

28. The site where gas exchange occurs is
Capillaries
Decreased arterial perfusion
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Upper airways

29. What is a definition of a delusion?
Preschool is cause and effect - school age begins to use logical thought process.
Initial assessment
Pt's underlying feelings
A false - fixed belief that cannot be corrected through reasoning.

30. An infant is in which Paiget stage?
Sensory motor
Knowing What to do/how to make a decision based upon available data.
Pain in legs assoc w walking
Decreased sense of taste

31. At What age do you begin to put thoughts into words?
Initial assessment
Toddler
Implementation
Secondary

32. What are the components of a mental status exam that are not part of a regular assessment?
Disorganized thinking and altered LOC
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
Serves to expedite dx and tx of actual and potential health problems
Nurse

33. What is responsible for transporting O2 in the blood
Non - opiod (ex: NSAID/acetominaphen)
Hemoglobin
To simulate eating motions with the hands
To ID the problem

34. Blood passes through the heart valves In what order?
A personal experience that does whatever the person in pain says it does
Preschool is cause and effect - school age begins to use logical thought process.
Tricuspid - mitral and the aortic
Adolescence

35. At What age do you begin to use logical thought process?
The medication will not affect the patient's breathing.
School age childen
EdFED- Q
To simulate eating motions with the hands

36. Examples of personal information
To ID the problem
Hygeine - DOB - work hx
Viral infection
Nursing dx

37. The order of air flow into the lungs is
Pain on inspiration and expiration; superficial squeaking or grating
Nurse
Pt's with oxygenation and perfusion problems
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli

38. Why are young children at greater risk for respiratory infection?
Secondary
Pain in legs assoc w walking
Immature immune system - structures close together lends to easy spreading from on area to another.
Risk of falls increases

39. What factors may indicate plural rub?
Abstract thinking
Pain in legs assoc w walking
ID'ing status of exisiting problems and locating new issues
Pain on inspiration and expiration; superficial squeaking or grating

40. When noticing a patient with dementia has stopped eating - the RN's first response is?
The patient
Hygeine - DOB - work hx
To simulate eating motions with the hands
A personal experience that does whatever the person in pain says it does

41. Where can you hear bronchovesicular breath sounds?
Secondary soureces (family - friends)
Preschool is cause and effect - school age begins to use logical thought process.
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Broncial (heard over trachea)

42. Sleep deprivation can effect
Learning - memory and adaptation to stress
A false - fixed belief that cannot be corrected through reasoning.
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Upper airways

43. Where can wheezes best be heard?
Trend assessment (shift report)
Upper airways
Pt's underlying feelings
Decision assessment

44. What is the cognitive difference between a preschooler and schoolage child?
Loss of taste
Risk of falls increases
Nurse
Preschool is cause and effect - school age begins to use logical thought process.

45. Nursing dx provides basis of
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
Communicate using hands and eyes.
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
Interventions for which the nurse is accountable

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

47. Are changes in vital signs a reliable indicator of chronic pain?
Symptoms
Implementation
Have them do simple math problems
No

48. The fifth vital sign is
Pain
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Ask - Believe - Choose - Deliver - Empower

49. What is the nursing process?
Data collection - data validation - data organization - data analysis - and data reporting/recording.
To simulate eating motions with the hands
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.

50. When using restraints in a confused patient
Stroke volume x's heart rate
Risk of falls increases
Pain
A false - fixed belief that cannot be corrected through reasoning.