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Nursing Fundamentals 3

Instructions:

Answer 50 questions in 15 minutes.
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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 is pain?
Daily
Decision assessment
A personal experience that does whatever the person in pain says it does
# of packs per day x # of years smoked

2. What is a definition of a delusion?
A false - fixed belief that cannot be corrected through reasoning.
Hemoglobin
Trend assessment (shift report)
Decreased sense of taste

3. A patient that is easily fatigued may have a HgB lab value of?
Hemoglobin
8.4
Stroke volume x's heart rate
Secondary soureces (family - friends)

4. At What age do you begin to use decision making?
Adolescence
Abstract thinking
Disorganized thinking and altered LOC
Surgically implanted device for deaf or hard or hearing - also called bionic ear.

5. At patient that state their shoes are tighter at the end of the day may be experiencing
Assess over all health status and identify the problem
Edema
Decreased arterial perfusion
Implementation

6. What is a chochlear implant?
Fast and deep respirations seen in patient's with acidosis
The result is accurate patient dB
Viral infection
Surgically implanted device for deaf or hard or hearing - also called bionic ear.

7. Intermittent claudication is caused by?
Upper airways
Having to use more than one pillow when sleeping
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Decreased arterial perfusion

8. Where can wheezes best be heard?
Preschool is cause and effect - school age begins to use logical thought process.
No
Upper airways
Disorganized thinking and altered LOC

9. Orthopnea is described as?
Double check equip and patient
School age childen
Pt's with oxygenation and perfusion problems
Having to use more than one pillow when sleeping

10. An infant is in which Paiget stage?
Sensory motor
Defining a baseline of cognitive function - any changes or deviations from norm.
Trauma or illness
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy

11. What factors may indicate plural rub?
Focused
Pain on inspiration and expiration; superficial squeaking or grating
Confusion Assessment Method
School age childen

12. The site where gas exchange occurs is
Vesicular (peripheral lung areas)
ID'ing status of exisiting problems and locating new issues
Capillaries
Upper airways

13. An ongoing assessment is performed
Daily
Edema
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)

14. Inspiration sounds are heard longer than expiration sounds In What area?
The process of storing - learning - retrieving - and using info.
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Vesicular (peripheral lung areas)
Symptoms

15. Subjective data could include
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Upper airways
Confusion Assessment Method
Symptoms

16. What is the cognitive difference between a preschooler and schoolage child?
Preschool is cause and effect - school age begins to use logical thought process.
Ask - Believe - Choose - Deliver - Empower
Risk of falls increases
Tricuspid - mitral and the aortic

17. An example of a primary source is
The patient
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Adolescence
The medication will not affect the patient's breathing.

18. Another term for a focused assessment is
Immature immune system - structures close together lends to easy spreading from on area to another.
Nursing dx
Ongoing assessment
Bacterial infection

19. Once a medical dx has been made - who is accountable for the reporting s/s of complications?
Sensory motor
Nurse
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Daily

20. What are the ABCDE's of pain management?
To simulate eating motions with the hands
Ask - Believe - Choose - Deliver - Empower
Secondary
8.4

21. Would a nursing dx be part of the primary or secondary dx?
Wandering
Secondary
To ID the problem
Pain

22. Name the 5 'W's' of assessing a change in LOC
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Daily
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Capillaries

23. What is the correct approach when dealing with older adults?
Toddler
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Upper airways
8.4

24. One way to test a person's cognitive ability and abstract thinking ability would be to
ID'ing status of exisiting problems and locating new issues
Have them do simple math problems
Decision assessment
Fast and deep respirations seen in patient's with acidosis

25. All body system data is not necessary which type of assessment
The process of storing - learning - retrieving - and using info.
Focused
Upper airways
# of packs per day x # of years smoked

26. When a patient has increased neutrophils - this may indicate what?
Adolescence
Bacterial infection
To simulate eating motions with the hands
Level of stress - risk for violence - anxiety level - patient unmet needs

27. Acceptable sources of assessment data when evaluating a confused patient would be
Secondary soureces (family - friends)
Disorganized thinking and altered LOC
Tricuspid - mitral and the aortic
Objective

28. The basis for a plan of care comes for which stage of the nursing process?
Nursing dx
Initial assessment
Ask - Believe - Choose - Deliver - Empower
Serves to expedite dx and tx of actual and potential health problems

29. What does CAM stand for
School age childen
Confusion Assessment Method
Pain
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts

30. When speaking with a patient with moderate hearing loss the RN should
Immature immune system - structures close together lends to easy spreading from on area to another.
Ask - Believe - Choose - Deliver - Empower
Communicate using hands and eyes.
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.

31. Types of hearing loss include
To ID the problem
Trauma or illness
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
Disorganized thinking and altered LOC

32. What are the steps of the nursing process?
The patient
Inattention and acute increase/decrease in cognitive function
Communicate using hands and eyes.
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation

33. At What age do you begin to put thoughts into words?
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Double check equip and patient
Toddler
Trend assessment (shift report)

34. What do rales sound like?
Nursing dx
Snap - crackle - pops; velcro - bubble wrap
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Trend assessment (shift report)

35. Expiration sounds are heard longer than inspiration In What area?
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Broncial (heard over trachea)
The process of storing - learning - retrieving - and using info.
Loss of taste

36. Side effects of putting confused pts in restraints include
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Loss of taste
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Viral infection

37. What is a component of the cognitive part of critical thinking skills?
A personal experience that does whatever the person in pain says it does
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
Knowing What to do/how to make a decision based upon available data.
Having to use more than one pillow when sleeping

38. At What age do you begin to use logical thought process?
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Toddler
Nursing
School age childen

39. Are changes in vital signs a reliable indicator of chronic pain?
Edema
No
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)

40. Which patient would be most likely to experience sensory overload?
Pain
Preschool is cause and effect - school age begins to use logical thought process.
An 80 y/o patient that has emergency surgery
Assess over all health status and identify the problem

41. Diabetes is a _________ dx
Pt's with oxygenation and perfusion problems
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Adolescence
Medical

42. Data validation assures
Secondary
The result is accurate patient dB
Learning - memory and adaptation to stress
Tricuspid - mitral and the aortic

43. What do rhonchi sound like?
Communicate using hands and eyes.
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Pain in legs assoc w walking

44. Data from the last 24/48 hours that included patterns would be a part of
Viral infection
Risk of falls increases
Trend assessment (shift report)
Upper airways

45. What would cause changes in congitive development later in life (middle adulthood)?
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
The patient
A personal experience that does whatever the person in pain says it does
Trauma or illness

46. What is the purpose of the nursing process?
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Irregular respirations (fast/slow) often seen at end of life
To ID the problem
Serves to expedite dx and tx of actual and potential health problems

47. What is the formula for cardiac output?

48. What is the difference between a nursing dx and a med dx?
Hemoglobin
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Pain
Medical

49. Describe the purpose of a mental status exam
Pain
Edema
No
Defining a baseline of cognitive function - any changes or deviations from norm.

50. When using restraints in a confused patient
Risk of falls increases
Abstract thinking
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Having to use more than one pillow when sleeping

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Nursing Fundamentals 3

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