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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. What are Piaget's stages of cognitive development
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Viral infection
Pt's underlying feelings

2. Another term for a focused assessment is
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Immature immune system - structures close together lends to easy spreading from on area to another.
Adolescence
Ongoing assessment

3. What scale is used to determine eating and feeding issues in adults with confusion
Fast and deep respirations seen in patient's with acidosis
Initial assessment
EdFED- Q
Broncial (heard over trachea)

4. Two indicators that are REQUIRED for classification via the CAM tool include
Medical
Decreased sense of taste
Inattention and acute increase/decrease in cognitive function
Adolescence

5. The path of blood from the heart to the lungs is
Level of stress - risk for violence - anxiety level - patient unmet needs
Tricuspid - mitral and the aortic
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins

6. 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.
Abstract thinking
Non - opiod (ex: NSAID/acetominaphen)
The process of storing - learning - retrieving - and using info.

7. Nursing interventions should be based on who's theory?
Irregular respirations (fast/slow) often seen at end of life
To simulate eating motions with the hands
An 80 y/o patient that has emergency surgery
Maslow

8. At patient that state their shoes are tighter at the end of the day may be experiencing
# of packs per day x # of years smoked
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Edema
Hemoglobin

9. The fifth vital sign is
A personal experience that does whatever the person in pain says it does
Pain
Trend assessment (shift report)
Disorganized thinking and altered LOC

10. What is the difference between hallucination and delirium?
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Communicate using hands and eyes.
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
Assess over all health status and identify the problem

11. What does CAM stand for
Immature immune system - structures close together lends to easy spreading from on area to another.
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Confusion Assessment Method
Pain on inspiration and expiration; superficial squeaking or grating

12. Once a medical dx has been made - who is accountable for the reporting s/s of complications?
Nurse
Viral infection
Double check equip and patient
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.

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

14. An ongoing assessment is performed
Trauma or illness
Maslow
Secondary soureces (family - friends)
Daily

15. Ongoing assessments are useful in

16. An example of a primary source is
Having to use more than one pillow when sleeping
The patient
The result is accurate patient dB
Decreased sense of taste

17. What is the formula for cardiac output?

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

19. When speaking with a patient with moderate hearing loss the RN should
Communicate using hands and eyes.
Initial assessment
Immature immune system - structures close together lends to easy spreading from on area to another.
Fast and deep respirations seen in patient's with acidosis

20. Blood passes through the heart valves In what order?
Tricuspid - mitral and the aortic
Pain
The medication will not affect the patient's breathing.
ID'ing status of exisiting problems and locating new issues

21. What do rales sound like?
The medication will not affect the patient's breathing.
Ongoing assessment
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Snap - crackle - pops; velcro - bubble wrap

22. The basis for a plan of care comes for which stage of the nursing process?
Secondary
Nursing dx
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
Surgically implanted device for deaf or hard or hearing - also called bionic ear.

23. Intermittent claudication is caused by?
Toddler
No
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Decreased arterial perfusion

24. What are Cheyne Stokes?
Adolescence
Level of stress - risk for violence - anxiety level - patient unmet needs
Defining a baseline of cognitive function - any changes or deviations from norm.
Irregular respirations (fast/slow) often seen at end of life

25. The purpose of an initial assessment is
Hemoglobin
Edema
To ID the problem
Knowing What to do/how to make a decision based upon available data.

26. A patient failing to answer questions or displaying a reluctance to participate in group or family activities may be experiencing
Hearing loss
To simulate eating motions with the hands
Preschool is cause and effect - school age begins to use logical thought process.
Data collection - data validation - data organization - data analysis - and data reporting/recording.

27. If an abnormal finding is revealed during assessment - the nurse should
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Double check equip and patient
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli

28. All body system data is not necessary which type of assessment
Focused
Fluid volume deficit related to poor intake
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
Tricuspid - mitral and the aortic

29. What is intermittent claudication?
To simulate eating motions with the hands
Pain in legs assoc w walking
Trauma or illness
Wandering

30. Where can you hear bronchovesicular breath sounds?
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
A personal experience that does whatever the person in pain says it does
Learning - memory and adaptation to stress
Secondary

31. Subjective data could include
Hemoglobin
Immature immune system - structures close together lends to easy spreading from on area to another.
Symptoms
Eye hygeine - accomodating factors - what was the level of decline - how long has it been

32. An infant is in which Paiget stage?
Trend assessment (shift report)
Knowing What to do/how to make a decision based upon available data.
Sensory motor
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation

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

34. Data gathered via instrumention (pulse ox) is considered
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Hygeine - DOB - work hx
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
Objective

35. Expiration sounds are heard longer than inspiration In What area?
Nursing dx
Broncial (heard over trachea)
Abstract thinking
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital

36. Fluid volume deficit is a __________ dx
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
Nursing
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)

37. Name the 5 'W's' of assessing a change in LOC
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Objective
Loss of taste
Nursing

38. What are the steps of the nursing process?
Hearing loss
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Toddler
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation

39. When performing an ongoing assessment for a patient with disturbed thinking the nurse should be sure to include
Level of stress - risk for violence - anxiety level - patient unmet needs
Assess over all health status and identify the problem
Focused
Preschool is cause and effect - school age begins to use logical thought process.

40. What is cognition?
Sensory motor
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Hearing loss
The process of storing - learning - retrieving - and using info.

41. When a patient has increased lymphocytes - this may indicate what?
The result is accurate patient dB
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Viral infection
Family - spouse - someone other than a healthcare worker - previous medical records.

42. Are changes in vital signs a reliable indicator of chronic pain?
Medical
No
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Symptoms

43. What is the correct approach when dealing with older adults?
Interventions for which the nurse is accountable
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
# of packs per day x # of years smoked
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response

44. Which patient would be most likely to experience sensory overload?
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
Defining a baseline of cognitive function - any changes or deviations from norm.
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
An 80 y/o patient that has emergency surgery

45. What factors may indicate plural rub?
Pain on inspiration and expiration; superficial squeaking or grating
Disorganized thinking and altered LOC
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Trauma or illness

46. What is the formula for determining pack years?
Vesicular (peripheral lung areas)
ID'ing status of exisiting problems and locating new issues
# of packs per day x # of years smoked
Pain

47. Would a nursing dx be part of the primary or secondary dx?
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Secondary
Bacterial infection
Symptoms

48. Hypogeusis is
Broncial (heard over trachea)
Pain on inspiration and expiration; superficial squeaking or grating
Decreased sense of taste
Hearing loss

49. The assessment that includes the patient's overhall health status
Objective
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
Focused
Initial assessment

50. The order of air flow into the lungs is
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
Bacterial infection
# of packs per day x # of years smoked
Stroke volume x's heart rate