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 is a chochlear implant?
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Secondary
Vesicular (peripheral lung areas)
Abstract thinking


2. Other factors that may indicate confusion using the CAM tool could be
Decision assessment
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Disorganized thinking and altered LOC
Having to use more than one pillow when sleeping


3. Hypogeusis is
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Decreased sense of taste
The process of storing - learning - retrieving - and using info.
Defining a baseline of cognitive function - any changes or deviations from norm.


4. Once a medical dx has been made - who is accountable for the reporting s/s of complications?
Nurse
Preschool is cause and effect - school age begins to use logical thought process.
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
8.4


5. Examples of personal information
Confusion Assessment Method
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
Hygeine - DOB - work hx
Hearing loss


6. What is cognition?
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
The process of storing - learning - retrieving - and using info.
Decision assessment
A personal experience that does whatever the person in pain says it does


7. 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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8. What are Piaget's stages of cognitive development
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
Secondary
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Immature immune system - structures close together lends to easy spreading from on area to another.


9. What is a definition of a delusion?
A false - fixed belief that cannot be corrected through reasoning.
Decision assessment
Immature immune system - structures close together lends to easy spreading from on area to another.
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)


10. What are the components of a mental status exam that are not part of a regular assessment?
Sensory motor
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
Medical
Pain on inspiration and expiration; superficial squeaking or grating


11. What is the correct approach when dealing with older adults?
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Secondary soureces (family - friends)
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
School age childen


12. An example of a primary source is
Pain
Secondary
Viral infection
The patient


13. Two indicators that are REQUIRED for classification via the CAM tool include
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
To simulate eating motions with the hands
Immature immune system - structures close together lends to easy spreading from on area to another.
Inattention and acute increase/decrease in cognitive function


14. What is a component of the cognitive part of critical thinking skills?
Knowing What to do/how to make a decision based upon available data.
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
Communicate using hands and eyes.
Nursing dx


15. Why are young children at greater risk for respiratory infection?
Immature immune system - structures close together lends to easy spreading from on area to another.
Preschool is cause and effect - school age begins to use logical thought process.
Non - opiod (ex: NSAID/acetominaphen)
Wandering


16. Keeping patient's belongings - shoes - suitcases and street clothes - etc. out of view are helpful for preventing: wandering?
Decision assessment
The process of storing - learning - retrieving - and using info.
Wandering
Double check equip and patient


17. The basis for a plan of care comes for which stage of the nursing process?
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Nursing dx
Pain
Immature immune system - structures close together lends to easy spreading from on area to another.


18. The path of blood from the lungs to the heart is
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Viral infection
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Sensory motor


19. What is the formula for cardiac output?

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20. If patient reports pain of 3 on scale of 0-10 - What is the appropriate class of pain reliever?
Hearing loss
Risk of falls increases
Non - opiod (ex: NSAID/acetominaphen)
The medication will not affect the patient's breathing.


21. Expiration sounds are heard longer than inspiration In What area?
Wandering
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Inattention and acute increase/decrease in cognitive function
Broncial (heard over trachea)


22. A potential adverse rx of chemically restraining a confused patient would be
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
Edema
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Paradoxical reaction


23. Asking a patient what would you do if there is a fire in the wastebasket - is a way to assess their
Abstract thinking
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Irregular respirations (fast/slow) often seen at end of life
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -


24. An example of a secondary source is
Family - spouse - someone other than a healthcare worker - previous medical records.
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Risk of falls increases
A personal experience that does whatever the person in pain says it does


25. What factors may indicate plural rub?
Maslow
Pain on inspiration and expiration; superficial squeaking or grating
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
A personal experience that does whatever the person in pain says it does


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

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27. At What age do you begin to use decision making?
An 80 y/o patient that has emergency surgery
Risk of falls increases
Adolescence
Edema


28. When noticing a patient with dementia has stopped eating - the RN's first response is?
To simulate eating motions with the hands
Implementation
To ID the problem
Abstract thinking


29. Where can wheezes best be heard?
Preschool is cause and effect - school age begins to use logical thought process.
Upper airways
Family - spouse - someone other than a healthcare worker - previous medical records.
Double check equip and patient


30. The path of blood from the heart to the lungs is
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Decision assessment
Have them do simple math problems


31. A patient that is easily fatigued may have a HgB lab value of?
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
8.4
The medication will not affect the patient's breathing.
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins


32. What is the formula for determining pack years?
The result is accurate patient dB
8.4
# of packs per day x # of years smoked
Secondary


33. Which patient would be most likely to experience sensory overload?
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Pt's with oxygenation and perfusion problems
Confusion Assessment Method
An 80 y/o patient that has emergency surgery


34. 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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35. Ageusia is
Paradoxical reaction
Focused
Having to use more than one pillow when sleeping
Loss of taste


36. At What age do you begin to use logical thought process?
8.4
Stroke volume x's heart rate
Paradoxical reaction
School age childen


37. Inspiration sounds are heard longer than expiration sounds In What area?
Irregular respirations (fast/slow) often seen at end of life
Stroke volume x's heart rate
Fast and deep respirations seen in patient's with acidosis
Vesicular (peripheral lung areas)


38. At What age do you begin to put thoughts into words?
Confusion Assessment Method
Pain
Interventions for which the nurse is accountable
Toddler


39. Orthopnea is described as?
Having to use more than one pillow when sleeping
Non - opiod (ex: NSAID/acetominaphen)
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Abstract thinking


40. What is intermittent claudication?
Have them do simple math problems
Capillaries
Pain in legs assoc w walking
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances


41. When performing an interview with a patient with vision loss - select the correct questions for obtaining an accurate vision history
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Broncial (heard over trachea)
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
8.4


42. An ongoing assessment is performed
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
Snap - crackle - pops; velcro - bubble wrap
Implementation
Daily


43. In Which part of the nursing process will you find delegation?
Implementation
Communicate using hands and eyes.
An 80 y/o patient that has emergency surgery
8.4


44. Data from the last 24/48 hours that included patterns would be a part of
To simulate eating motions with the hands
Trend assessment (shift report)
Initial assessment
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)


45. Ongoing assessments are useful in

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46. What is pain?
Ongoing assessment
Implementation
A personal experience that does whatever the person in pain says it does
School age childen


47. 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.
The medication will not affect the patient's breathing.
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Nurse


48. Types of hearing loss include
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Snap - crackle - pops; velcro - bubble wrap
Serves to expedite dx and tx of actual and potential health problems
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)


49. What are the ABCDE's of pain management?
Ask - Believe - Choose - Deliver - Empower
Medical
Pain on inspiration and expiration; superficial squeaking or grating
Abstract thinking


50. What is the difference between a nursing dx and a med dx?
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Interventions for which the nurse is accountable
Focused
An 80 y/o patient that has emergency surgery