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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 Cheyne Stokes?
Irregular respirations (fast/slow) often seen at end of life
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Snap - crackle - pops; velcro - bubble wrap
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital

2. What are Piaget's stages of cognitive development
Broncial (heard over trachea)
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
Hearing loss

3. At patient that state their shoes are tighter at the end of the day may be experiencing
Decreased sense of taste
Edema
Fluid volume deficit related to poor intake
Toddler

4. Diabetes is a _________ dx
Maslow
Medical
Nurse
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.

5. What is cognition?
Ongoing assessment
Stroke volume x's heart rate
Pain on inspiration and expiration; superficial squeaking or grating
The process of storing - learning - retrieving - and using info.

6. Once a medical dx has been made - who is accountable for the reporting s/s of complications?
Nurse
Communicate using hands and eyes.
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
Decreased arterial perfusion

7. What are the components of a mental status exam that are not part of a regular assessment?
Daily
Initial assessment
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
Have them do simple math problems

8. What is a component of the cognitive part of critical thinking skills?
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
Data collection - data validation - data organization - data analysis - and data reporting/recording.
8.4
Knowing What to do/how to make a decision based upon available data.

9. Data validation assures
Pain in legs assoc w walking
Viral infection
Nursing
The result is accurate patient dB

10. A patient failing to answer questions or displaying a reluctance to participate in group or family activities may be experiencing
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Hearing loss
Hemoglobin
Fluid volume deficit related to poor intake

11. All body system data is not necessary which type of assessment
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Level of stress - risk for violence - anxiety level - patient unmet needs
Focused
Ongoing assessment

12. The path of blood from the heart to the lungs is
# of packs per day x # of years smoked
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Maslow
Trauma or illness

13. The purpose of an intitial assement serves to?
Hygeine - DOB - work hx
Assess over all health status and identify the problem
Snap - crackle - pops; velcro - bubble wrap
Adolescence

14. What do rales sound like?
The result is accurate patient dB
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Snap - crackle - pops; velcro - bubble wrap

15. An example of a nursing dx would be
Nursing dx
Fluid volume deficit related to poor intake
Assess over all health status and identify the problem
Non - opiod (ex: NSAID/acetominaphen)

16. Kussamaul respirations describe

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17. The path of blood from the lungs to the heart is
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Ask - Believe - Choose - Deliver - Empower
8.4
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve

18. 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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19. The basis for a plan of care comes for which stage of the nursing process?
Pain
Double check equip and patient
Nursing dx
The medication will not affect the patient's breathing.

20. A nursing dx is best described as
Snap - crackle - pops; velcro - bubble wrap
The process of storing - learning - retrieving - and using info.
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
The patient

21. What scale is used to determine eating and feeding issues in adults with confusion
EdFED- Q
Communicate using hands and eyes.
Decreased arterial perfusion
Having to use more than one pillow when sleeping

22. Ongoing assessments are useful in

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23. Types of hearing loss include
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Edema

24. The purpose of an initial assessment is
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
A false - fixed belief that cannot be corrected through reasoning.
To ID the problem
Communicate using hands and eyes.

25. If an abnormal finding is revealed during assessment - the nurse should
Double check equip and patient
Wandering
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
The medication will not affect the patient's breathing.

26. Other factors that may indicate confusion using the CAM tool could be
Disorganized thinking and altered LOC
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.

27. When performing an ongoing assessment for a patient with disturbed thinking the nurse should be sure to include
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
Sensory motor
Level of stress - risk for violence - anxiety level - patient unmet needs
Maslow

28. Side effects of putting confused pts in restraints include
Loss of taste
Nurse
Tricuspid - mitral and the aortic
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy

29. Keeping patient's belongings - shoes - suitcases and street clothes - etc. out of view are helpful for preventing: wandering?
Wandering
Focused
Snap - crackle - pops; velcro - bubble wrap
Trend assessment (shift report)

30. Which patient would be most likely to experience sensory overload?
The result is accurate patient dB
Paradoxical reaction
Pain in legs assoc w walking
An 80 y/o patient that has emergency surgery

31. An ongoing assessment is performed
Fluid volume deficit related to poor intake
Pain in legs assoc w walking
Fast and deep respirations seen in patient's with acidosis
Daily

32. Hypogeusis is
Pt's with oxygenation and perfusion problems
Secondary
To simulate eating motions with the hands
Decreased sense of taste

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

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34. What is the difference between hallucination and delirium?
Tricuspid - mitral and the aortic
Objective
Inattention and acute increase/decrease in cognitive function
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.

35. What are the steps of the nursing process?
An 80 y/o patient that has emergency surgery
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
To ID the problem
Learning - memory and adaptation to stress

36. What factors may indicate plural rub?
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
No
Pain on inspiration and expiration; superficial squeaking or grating
Tricuspid - mitral and the aortic

37. Asking a patient what would you do if there is a fire in the wastebasket - is a way to assess their
Abstract thinking
The patient
Hygeine - DOB - work hx
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli

38. The assessment that includes the patient's overhall health status
To ID the problem
No
Snap - crackle - pops; velcro - bubble wrap
Initial assessment

39. One way to test a person's cognitive ability and abstract thinking ability would be to
A false - fixed belief that cannot be corrected through reasoning.
Learning - memory and adaptation to stress
Have them do simple math problems
Symptoms

40. What is the correct approach when dealing with older adults?
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
Double check equip and patient
Pt's with oxygenation and perfusion problems
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response

41. An example of a secondary source is
No
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Nursing dx
Family - spouse - someone other than a healthcare worker - previous medical records.

42. QUESTT is a tool for What type of an assessment?
Loss of taste
Trauma or illness
The result is accurate patient dB
Pain

43. Intermittent claudication is caused by?
Inattention and acute increase/decrease in cognitive function
Decreased arterial perfusion
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve

44. The order of air flow into the lungs is
Upper airways
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
Defining a baseline of cognitive function - any changes or deviations from norm.

45. Blood passes through the heart valves In what order?
Tricuspid - mitral and the aortic
Knowing What to do/how to make a decision based upon available data.
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve

46. The site where gas exchange occurs is
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Trend assessment (shift report)
Capillaries
A false - fixed belief that cannot be corrected through reasoning.

47. What are the ABCDE's of pain management?
Symptoms
ID'ing status of exisiting problems and locating new issues
Ask - Believe - Choose - Deliver - Empower
To simulate eating motions with the hands

48. When using restraints in a confused patient
A false - fixed belief that cannot be corrected through reasoning.
Disorganized thinking and altered LOC
Risk of falls increases
Level of stress - risk for violence - anxiety level - patient unmet needs

49. Examples of personal information
Secondary soureces (family - friends)
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Hygeine - DOB - work hx

50. Subjective data could include
Decreased sense of taste
Symptoms
Irregular respirations (fast/slow) often seen at end of life
Wandering