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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. An example of a primary source is
Have them do simple math problems
The patient
Non - opiod (ex: NSAID/acetominaphen)
Capillaries

2. What is intermittent claudication?
Learning - memory and adaptation to stress
Nursing
Pain in legs assoc w walking
Focused

3. Name the 5 'W's' of assessing a change in LOC
Confusion Assessment Method
Secondary
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)

4. Hypogeusis is
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Decreased sense of taste
Medical
Fast and deep respirations seen in patient's with acidosis

5. What is a chochlear implant?
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.
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
ID'ing status of exisiting problems and locating new issues

6. What would cause changes in congitive development later in life (middle adulthood)?
Trauma or illness
Double check equip and patient
Ask - Believe - Choose - Deliver - Empower
Non - opiod (ex: NSAID/acetominaphen)

7. What is the formula for determining pack years?
Toddler
The result is accurate patient dB
# of packs per day x # of years smoked
Trauma or illness

8. At What age do you begin to use decision making?
Loss of taste
Double check equip and patient
Adolescence
Stroke volume x's heart rate

9. A nursing dx is best described as
Level of stress - risk for violence - anxiety level - patient unmet needs
Preschool is cause and effect - school age begins to use logical thought process.
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli

10. Orthopnea is described as?
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Having to use more than one pillow when sleeping
Trauma or illness
Family - spouse - someone other than a healthcare worker - previous medical records.

11. In Which part of the nursing process will you find delegation?
Objective
Interventions for which the nurse is accountable
Implementation
Medical

12. Factors that may reduce the efficacy of pulse oximetry include
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Pain
Ongoing assessment

13. A potential adverse rx of chemically restraining a confused patient would be
8.4
To simulate eating motions with the hands
Paradoxical reaction
Knowing What to do/how to make a decision based upon available data.

14. Describe the purpose of a mental status exam
Fast and deep respirations seen in patient's with acidosis
Trend assessment (shift report)
Defining a baseline of cognitive function - any changes or deviations from norm.
Medical

15. Examples of personal information
Loss of taste
Hygeine - DOB - work hx
Tricuspid - mitral and the aortic
Nursing dx

16. The order of air flow into the lungs is
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
Initial assessment
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
A false - fixed belief that cannot be corrected through reasoning.

17. The purpose of an intitial assement serves to?
Level of stress - risk for violence - anxiety level - patient unmet needs
Secondary
Assess over all health status and identify the problem
Confusion Assessment Method

18. An example of a secondary source is
Vesicular (peripheral lung areas)
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Family - spouse - someone other than a healthcare worker - previous medical records.
Objective

19. What is the correct approach when dealing with older adults?
Serves to expedite dx and tx of actual and potential health problems
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Stroke volume x's heart rate

20. What are the ABCDE's of pain management?
Ask - Believe - Choose - Deliver - Empower
Vesicular (peripheral lung areas)
The result is accurate patient dB
# of packs per day x # of years smoked

21. Once a medical dx has been made - who is accountable for the reporting s/s of complications?
Non - opiod (ex: NSAID/acetominaphen)
Pt's underlying feelings
Defining a baseline of cognitive function - any changes or deviations from norm.
Nurse

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

23. At What age do you begin to use logical thought process?
Snap - crackle - pops; velcro - bubble wrap
Capillaries
School age childen
Defining a baseline of cognitive function - any changes or deviations from norm.

24. Inspiration sounds are heard longer than expiration sounds In What area?
A personal experience that does whatever the person in pain says it does
Pt's underlying feelings
Vesicular (peripheral lung areas)
Secondary soureces (family - friends)

25. Where can wheezes best be heard?
Upper airways
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Pain on inspiration and expiration; superficial squeaking or grating
A false - fixed belief that cannot be corrected through reasoning.

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

27. One way to test a person's cognitive ability and abstract thinking ability would be to
Having to use more than one pillow when sleeping
Have them do simple math problems
Nursing
No

28. What does CAM stand for
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
Medical
Ask - Believe - Choose - Deliver - Empower
Confusion Assessment Method

29. An example of a nursing dx would be
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
Fluid volume deficit related to poor intake
Non - opiod (ex: NSAID/acetominaphen)
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response

30. The fifth vital sign is
Communicate using hands and eyes.
Pain
Irregular respirations (fast/slow) often seen at end of life
Abstract thinking

31. Intermittent claudication is caused by?
Decreased arterial perfusion
ID'ing status of exisiting problems and locating new issues
Interventions for which the nurse is accountable
Secondary soureces (family - friends)

32. Another term for a focused assessment is
Ongoing assessment
Hemoglobin
Maslow
The patient

33. An ongoing assessment is performed
No
To ID the problem
Objective
Daily

34. Other factors that may indicate confusion using the CAM tool could be
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Disorganized thinking and altered LOC
Level of stress - risk for violence - anxiety level - patient unmet needs
Hearing loss

35. What are Cheyne Stokes?
Fluid volume deficit related to poor intake
Irregular respirations (fast/slow) often seen at end of life
Level of stress - risk for violence - anxiety level - patient unmet needs
Paradoxical reaction

36. When performing an ongoing assessment for a patient with disturbed thinking the nurse should be sure to include
Hemoglobin
Viral infection
Level of stress - risk for violence - anxiety level - patient unmet needs
A personal experience that does whatever the person in pain says it does

37. Acceptable sources of assessment data when evaluating a confused patient would be
Secondary soureces (family - friends)
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
Pain on inspiration and expiration; superficial squeaking or grating
Decreased sense of taste

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

39. Fluid volume deficit is a __________ dx
Nursing
Daily
Fast and deep respirations seen in patient's with acidosis
Non - opiod (ex: NSAID/acetominaphen)

40. What is the nursing process?
A personal experience that does whatever the person in pain says it does
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Secondary
Ongoing assessment

41. Blood passes through the heart valves In what order?
Hearing loss
Tricuspid - mitral and the aortic
Stroke volume x's heart rate
Eye hygeine - accomodating factors - what was the level of decline - how long has it been

42. 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.
Risk of falls increases
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.

43. The site where gas exchange occurs is
Capillaries
Serves to expedite dx and tx of actual and potential health problems
Disorganized thinking and altered LOC
Preschool is cause and effect - school age begins to use logical thought process.

44. What factors may indicate plural rub?
ID'ing status of exisiting problems and locating new issues
Trend assessment (shift report)
Snap - crackle - pops; velcro - bubble wrap
Pain on inspiration and expiration; superficial squeaking or grating

45. At patient that state their shoes are tighter at the end of the day may be experiencing
Edema
Bacterial infection
Hearing loss
Daily

46. Expiration sounds are heard longer than inspiration In What area?
Broncial (heard over trachea)
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Implementation
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital

47. The basis for a plan of care comes for which stage of the nursing process?
Hemoglobin
Fast and deep respirations seen in patient's with acidosis
Pain
Nursing dx

48. All body system data is not necessary which type of assessment
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
Focused
Preschool is cause and effect - school age begins to use logical thought process.
Secondary soureces (family - friends)

49. What are the components of a mental status exam that are not part of a regular assessment?
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
Wandering
A false - fixed belief that cannot be corrected through reasoning.

50. Which patient would be most likely to experience sensory overload?
An 80 y/o patient that has emergency surgery
Broncial (heard over trachea)
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
8.4