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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. At patient that state their shoes are tighter at the end of the day may be experiencing
Trauma or illness
Hygeine - DOB - work hx
Wandering
Edema

2. An example of a secondary source is
Family - spouse - someone other than a healthcare worker - previous medical records.
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
Objective
Initial assessment

3. What is the cognitive difference between a preschooler and schoolage child?
Assess over all health status and identify the problem
Decision assessment
No
Preschool is cause and effect - school age begins to use logical thought process.

4. What is cognition?
Assess over all health status and identify the problem
Hearing loss
Capillaries
The process of storing - learning - retrieving - and using info.

5. The assessment that includes the patient's overhall health status
Assess over all health status and identify the problem
Interventions for which the nurse is accountable
Secondary soureces (family - friends)
Initial assessment

6. Why are young children at greater risk for respiratory infection?
Adolescence
Communicate using hands and eyes.
Nurse
Immature immune system - structures close together lends to easy spreading from on area to another.

7. Ongoing assessments are useful in

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8. What is the nursing process?
Hemoglobin
An 80 y/o patient that has emergency surgery
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Interventions for which the nurse is accountable

9. An ongoing assessment is performed
Daily
8.4
Wandering
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital

10. The site where gas exchange occurs is
Capillaries
Non - opiod (ex: NSAID/acetominaphen)
Pain
Pain on inspiration and expiration; superficial squeaking or grating

11. Name the 5 'W's' of assessing a change in LOC
Nursing
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Abstract thinking
Immature immune system - structures close together lends to easy spreading from on area to another.

12. Ageusia is
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Loss of taste
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Focused

13. Factors that may reduce the efficacy of pulse oximetry include
Sensory motor
Hemoglobin
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Pain

14. What is the correct approach when dealing with older adults?
Pain on inspiration and expiration; superficial squeaking or grating
Preschool is cause and effect - school age begins to use logical thought process.
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
An 80 y/o patient that has emergency surgery

15. What is intermittent claudication?
Sensory motor
Secondary
Pain in legs assoc w walking
Pain

16. What are the steps of the nursing process?
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Maslow
Adolescence
The patient

17. Keeping patient's belongings - shoes - suitcases and street clothes - etc. out of view are helpful for preventing: wandering?
Wandering
Irregular respirations (fast/slow) often seen at end of life
Snap - crackle - pops; velcro - bubble wrap
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)

18. Subjective data could include
Symptoms
Objective
To ID the problem
Secondary soureces (family - friends)

19. What are the components of a mental status exam that are not part of a regular assessment?
Nursing dx
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
Non - opiod (ex: NSAID/acetominaphen)
Confusion Assessment Method

20. What is a chochlear implant?
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
A personal experience that does whatever the person in pain says it does
To ID the problem
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve

21. An example of a nursing dx would be
Pain in legs assoc w walking
Fluid volume deficit related to poor intake
Disorganized thinking and altered LOC
EdFED- Q

22. A nursing dx is best described as
Pain
Maslow
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
Immature immune system - structures close together lends to easy spreading from on area to another.

23. What is the formula for cardiac output?

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24. Diabetes is a _________ dx
Secondary soureces (family - friends)
No
Fluid volume deficit related to poor intake
Medical

25. Expiration sounds are heard longer than inspiration In What area?
Risk of falls increases
Implementation
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Broncial (heard over trachea)

26. If patient reports pain of 3 on scale of 0-10 - What is the appropriate class of pain reliever?
Nurse
Non - opiod (ex: NSAID/acetominaphen)
Risk of falls increases
Serves to expedite dx and tx of actual and potential health problems

27. If an abnormal finding is revealed during assessment - the nurse should
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
Initial assessment
Serves to expedite dx and tx of actual and potential health problems
Double check equip and patient

28. The path of blood from the lungs to the heart is
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Ongoing assessment
Edema
Irregular respirations (fast/slow) often seen at end of life

29. What is the formula for determining pack years?
Stroke volume x's heart rate
Paradoxical reaction
Interventions for which the nurse is accountable
# of packs per day x # of years smoked

30. Data that is recorded for an immediate need (code blue or fall) would be included in
Communicate using hands and eyes.
To simulate eating motions with the hands
Decision assessment
Nursing

31. What does CAM stand for
Initial assessment
Pain
Fast and deep respirations seen in patient's with acidosis
Confusion Assessment Method

32. Nursing dx provides basis of
The result is accurate patient dB
Interventions for which the nurse is accountable
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli

33. A patient failing to answer questions or displaying a reluctance to participate in group or family activities may be experiencing
Hearing loss
Ongoing assessment
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Edema

34. Data gathered via instrumention (pulse ox) is considered
Pt's with oxygenation and perfusion problems
Objective
Tricuspid - mitral and the aortic
Abstract thinking

35. Types of hearing loss include
Interventions for which the nurse is accountable
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
Learning - memory and adaptation to stress
Loss of taste

36. Once a medical dx has been made - who is accountable for the reporting s/s of complications?
Double check equip and patient
Nurse
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
Eye hygeine - accomodating factors - what was the level of decline - how long has it been

37. The purpose of an initial assessment is
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
To ID the problem
Nurse
Loss of taste

38. When a patient has increased lymphocytes - this may indicate what?
To ID the problem
Wandering
The process of storing - learning - retrieving - and using info.
Viral infection

39. What is the purpose of the nursing process?
Daily
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Decreased sense of taste
Serves to expedite dx and tx of actual and potential health problems

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

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41. Describe the purpose of a mental status exam
Decision assessment
8.4
Secondary soureces (family - friends)
Defining a baseline of cognitive function - any changes or deviations from norm.

42. What factors may indicate plural rub?
Pain on inspiration and expiration; superficial squeaking or grating
Decreased sense of taste
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
Trend assessment (shift report)

43. A potential adverse rx of chemically restraining a confused patient would be
Capillaries
Abstract thinking
Paradoxical reaction
Hygeine - DOB - work hx

44. Would a nursing dx be part of the primary or secondary dx?
Secondary
Interventions for which the nurse is accountable
Pain in legs assoc w walking
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.

45. At What age do you begin to use decision making?
School age childen
Upper airways
Fluid volume deficit related to poor intake
Adolescence

46. The basis for a plan of care comes for which stage of the nursing process?
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Abstract thinking
Nurse
Nursing dx

47. At What age do you begin to use logical thought process?
Defining a baseline of cognitive function - any changes or deviations from norm.
Have them do simple math problems
School age childen
Focused

48. A patient that is easily fatigued may have a HgB lab value of?
Pt's underlying feelings
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
8.4
Inattention and acute increase/decrease in cognitive function

49. Data from the last 24/48 hours that included patterns would be a part of
School age childen
Pt's underlying feelings
Trend assessment (shift report)
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital

50. Acceptable sources of assessment data when evaluating a confused patient would be
Ask - Believe - Choose - Deliver - Empower
Secondary soureces (family - friends)
Daily
The result is accurate patient dB