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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. In Which part of the nursing process will you find delegation?
Have them do simple math problems
Implementation
Immature immune system - structures close together lends to easy spreading from on area to another.
Non - opiod (ex: NSAID/acetominaphen)

2. Inspiration sounds are heard longer than expiration sounds In What area?
Vesicular (peripheral lung areas)
Paradoxical reaction
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
No

3. Another term for a focused assessment is
Level of stress - risk for violence - anxiety level - patient unmet needs
Hearing loss
Pt's with oxygenation and perfusion problems
Ongoing assessment

4. Data that is recorded for an immediate need (code blue or fall) would be included in
Viral infection
Maslow
Decision assessment
Nurse

5. Describe the purpose of a mental status exam
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Defining a baseline of cognitive function - any changes or deviations from norm.
Fluid volume deficit related to poor intake
Tricuspid - mitral and the aortic

6. An example of a secondary source is
Maslow
Family - spouse - someone other than a healthcare worker - previous medical records.
Decision assessment
Inattention and acute increase/decrease in cognitive function

7. QUESTT is a tool for What type of an assessment?
Wandering
The patient
Pain
A false - fixed belief that cannot be corrected through reasoning.

8. At What age do you begin to use decision making?
Adolescence
Inattention and acute increase/decrease in cognitive function
Nurse
Secondary soureces (family - friends)

9. An example of a nursing dx would be
An 80 y/o patient that has emergency surgery
Nurse
The result is accurate patient dB
Fluid volume deficit related to poor intake

10. An ongoing assessment is performed
Decreased sense of taste
No
Tricuspid - mitral and the aortic
Daily

11. Intermittent claudication is caused by?
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Focused
Immature immune system - structures close together lends to easy spreading from on area to another.
Decreased arterial perfusion

12. A patient failing to answer questions or displaying a reluctance to participate in group or family activities may be experiencing
Daily
Pain
Hearing loss
EdFED- Q

13. A patient that is easily fatigued may have a HgB lab value of?
No
Decreased arterial perfusion
The process of storing - learning - retrieving - and using info.
8.4

14. What is the difference between a nursing dx and a med dx?
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Non - opiod (ex: NSAID/acetominaphen)
Ask - Believe - Choose - Deliver - Empower

15. The purpose of an intitial assement serves to?
Stroke volume x's heart rate
Focused
Nurse
Assess over all health status and identify the problem

16. When a patient has increased lymphocytes - this may indicate what?
Disorganized thinking and altered LOC
Risk of falls increases
Viral infection
Hemoglobin

17. A nursing dx is best described as
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
Secondary soureces (family - friends)
Decision assessment
Assess over all health status and identify the problem

18. What is a definition of a delusion?
Paradoxical reaction
A false - fixed belief that cannot be corrected through reasoning.
Defining a baseline of cognitive function - any changes or deviations from norm.
Stroke volume x's heart rate

19. What is the formula for determining pack years?
Edema
# of packs per day x # of years smoked
Medical
Hearing loss

20. Subjective data could include
Initial assessment
Symptoms
Sensory motor
Viral infection

21. Other factors that may indicate confusion using the CAM tool could be
Hearing loss
Risk of falls increases
Immature immune system - structures close together lends to easy spreading from on area to another.
Disorganized thinking and altered LOC

22. The assessment that includes the patient's overhall health status
Adolescence
Nurse
Initial assessment
Pain

23. What is responsible for transporting O2 in the blood
No
Hearing loss
Hemoglobin
Having to use more than one pillow when sleeping

24. What are Piaget's stages of cognitive development
School age childen
Pain
Loss of taste
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)

25. Diabetes is a _________ dx
Pain
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Medical
EdFED- Q

26. What are Cheyne Stokes?
Knowing What to do/how to make a decision based upon available data.
Irregular respirations (fast/slow) often seen at end of life
To ID the problem
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.

27. Two indicators that are REQUIRED for classification via the CAM tool include
To simulate eating motions with the hands
Inattention and acute increase/decrease in cognitive function
Preschool is cause and effect - school age begins to use logical thought process.
Surgically implanted device for deaf or hard or hearing - also called bionic ear.

28. What is cognition?
The process of storing - learning - retrieving - and using info.
Decreased arterial perfusion
Having to use more than one pillow when sleeping
Interventions for which the nurse is accountable

29. When using restraints in a confused patient
Pain
Trend assessment (shift report)
Defining a baseline of cognitive function - any changes or deviations from norm.
Risk of falls increases

30. What scale is used to determine eating and feeding issues in adults with confusion
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
Nurse
Trauma or illness
EdFED- Q

31. Sleep deprivation can effect
Ask - Believe - Choose - Deliver - Empower
The medication will not affect the patient's breathing.
Double check equip and patient
Learning - memory and adaptation to stress

32. When performing an interview with a patient with vision loss - select the correct questions for obtaining an accurate vision history
EdFED- Q
Pain on inspiration and expiration; superficial squeaking or grating
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Irregular respirations (fast/slow) often seen at end of life

33. What is the cognitive difference between a preschooler and schoolage child?
Assess over all health status and identify the problem
Preschool is cause and effect - school age begins to use logical thought process.
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Ongoing assessment

34. Data gathered via instrumention (pulse ox) is considered
Level of stress - risk for violence - anxiety level - patient unmet needs
Bacterial infection
Objective
Nursing

35. When speaking with a patient with moderate hearing loss the RN should
Risk of falls increases
Communicate using hands and eyes.
Broncial (heard over trachea)
Eye hygeine - accomodating factors - what was the level of decline - how long has it been

36. Examples of personal information
A false - fixed belief that cannot be corrected through reasoning.
Pt's with oxygenation and perfusion problems
Hygeine - DOB - work hx
The process of storing - learning - retrieving - and using info.

37. If patient reports pain of 3 on scale of 0-10 - What is the appropriate class of pain reliever?
Non - opiod (ex: NSAID/acetominaphen)
Broncial (heard over trachea)
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

38. A potential adverse rx of chemically restraining a confused patient would be
Snap - crackle - pops; velcro - bubble wrap
8.4
Pain in legs assoc w walking
Paradoxical reaction

39. An example of a primary source is
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
The patient
Capillaries
The process of storing - learning - retrieving - and using info.

40. Orthopnea is described as?
Having to use more than one pillow when sleeping
Ask - Believe - Choose - Deliver - Empower
No
Inattention and acute increase/decrease in cognitive function

41. Where can you hear bronchovesicular breath sounds?
The process of storing - learning - retrieving - and using info.
Risk of falls increases
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.

42. Why are young children at greater risk for respiratory infection?
Knowing What to do/how to make a decision based upon available data.
Abstract thinking
Learning - memory and adaptation to stress
Immature immune system - structures close together lends to easy spreading from on area to another.

43. Once a medical dx has been made - who is accountable for the reporting s/s of complications?
Immature immune system - structures close together lends to easy spreading from on area to another.
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
Nurse
Nursing dx

44. The basis for a plan of care comes for which stage of the nursing process?
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
A false - fixed belief that cannot be corrected through reasoning.
Nursing dx

45. The order of air flow into the lungs is
Secondary
Toddler
Confusion Assessment Method
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli

46. Where can wheezes best be heard?
Symptoms
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Upper airways
School age childen

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

48. Expiration sounds are heard longer than inspiration In What area?
Toddler
Daily
A personal experience that does whatever the person in pain says it does
Broncial (heard over trachea)

49. One way to test a person's cognitive ability and abstract thinking ability would be to
The process of storing - learning - retrieving - and using info.
Pt's with oxygenation and perfusion problems
Have them do simple math problems
Maslow

50. At What age do you begin to put thoughts into words?
Irregular respirations (fast/slow) often seen at end of life
Toddler
Vesicular (peripheral lung areas)
Fluid volume deficit related to poor intake