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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. Why are young children at greater risk for respiratory infection?
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
A false - fixed belief that cannot be corrected through reasoning.
EdFED- Q
Immature immune system - structures close together lends to easy spreading from on area to another.

2. Acceptable sources of assessment data when evaluating a confused patient would be
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
Viral infection
Secondary soureces (family - friends)
Assess over all health status and identify the problem

3. What is the cognitive difference between a preschooler and schoolage child?
Nursing
Ongoing assessment
Objective
Preschool is cause and effect - school age begins to use logical thought process.

4. Inspiration sounds are heard longer than expiration sounds In What area?
Interventions for which the nurse is accountable
Immature immune system - structures close together lends to easy spreading from on area to another.
Pain in legs assoc w walking
Vesicular (peripheral lung areas)

5. What factors may indicate plural rub?
Pain on inspiration and expiration; superficial squeaking or grating
The process of storing - learning - retrieving - and using info.
Serves to expedite dx and tx of actual and potential health problems
Ask - Believe - Choose - Deliver - Empower

6. QUESTT is a tool for What type of an assessment?
Pain in legs assoc w walking
Level of stress - risk for violence - anxiety level - patient unmet needs
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Pain

7. Where can wheezes best be heard?
Broncial (heard over trachea)
Upper airways
8.4
Capillaries

8. What is responsible for transporting O2 in the blood
Hemoglobin
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Secondary soureces (family - friends)
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli

9. What are Piaget's stages of cognitive development
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
A personal experience that does whatever the person in pain says it does
Secondary

10. What is a definition of a delusion?
Irregular respirations (fast/slow) often seen at end of life
A false - fixed belief that cannot be corrected through reasoning.
Abstract thinking
Pain in legs assoc w walking

11. Fluid volume deficit is a __________ dx
Vesicular (peripheral lung areas)
Daily
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Nursing

12. Diabetes is a _________ dx
Confusion Assessment Method
Nursing dx
Nursing
Medical

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

14. When speaking with a patient with moderate hearing loss the RN should
Serves to expedite dx and tx of actual and potential health problems
Fast and deep respirations seen in patient's with acidosis
Communicate using hands and eyes.
Family - spouse - someone other than a healthcare worker - previous medical records.

15. Data gathered via instrumention (pulse ox) is considered
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
Confusion Assessment Method
Objective
Upper airways

16. Which patient would be most likely to experience sensory overload?
Pt's with oxygenation and perfusion problems
An 80 y/o patient that has emergency surgery
To ID the problem
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)

17. 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
Capillaries
Risk of falls increases
Communicate using hands and eyes.

18. What would cause changes in congitive development later in life (middle adulthood)?
Trauma or illness
Tricuspid - mitral and the aortic
Nursing dx
Level of stress - risk for violence - anxiety level - patient unmet needs

19. What is pain?
Pt's underlying feelings
Secondary
Stroke volume x's heart rate
A personal experience that does whatever the person in pain says it does

20. What is the formula for determining pack years?
# of packs per day x # of years smoked
Ask - Believe - Choose - Deliver - Empower
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
Nursing dx

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

22. What does CAM stand for
An 80 y/o patient that has emergency surgery
Upper airways
Non - opiod (ex: NSAID/acetominaphen)
Confusion Assessment Method

23. The site where gas exchange occurs is
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
Capillaries
Medical
School age childen

24. Would a nursing dx be part of the primary or secondary dx?
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Focused
Secondary
Nurse

25. What are the steps of the nursing process?
Nursing dx
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Interventions for which the nurse is accountable
Hearing loss

26. When performing an ongoing assessment for a patient with disturbed thinking the nurse should be sure to include
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
Level of stress - risk for violence - anxiety level - patient unmet needs
Pain on inspiration and expiration; superficial squeaking or grating
Immature immune system - structures close together lends to easy spreading from on area to another.

27. Asking a patient what would you do if there is a fire in the wastebasket - is a way to assess their
Abstract thinking
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
The patient
The medication will not affect the patient's breathing.

28. Ageusia is
Loss of taste
Viral infection
Level of stress - risk for violence - anxiety level - patient unmet needs
School age childen

29. Intermittent claudication is caused by?
Learning - memory and adaptation to stress
An 80 y/o patient that has emergency surgery
Decreased arterial perfusion
Serves to expedite dx and tx of actual and potential health problems

30. Nursing dx provides basis of
Hygeine - DOB - work hx
Secondary soureces (family - friends)
Interventions for which the nurse is accountable
Irregular respirations (fast/slow) often seen at end of life

31. A patient failing to answer questions or displaying a reluctance to participate in group or family activities may be experiencing
Trauma or illness
Paradoxical reaction
Hearing loss
Irregular respirations (fast/slow) often seen at end of life

32. Hypogeusis is
Decreased sense of taste
Assess over all health status and identify the problem
8.4
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy

33. Are changes in vital signs a reliable indicator of chronic pain?
Pain
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
No
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.

34. What is the nursing process?
Decreased arterial perfusion
Symptoms
Tricuspid - mitral and the aortic
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.

35. The basis for a plan of care comes for which stage of the nursing process?
School age childen
Decision assessment
Nursing dx
Viral infection

36. Ongoing assessments are useful in

37. What scale is used to determine eating and feeding issues in adults with confusion
Ask - Believe - Choose - Deliver - Empower
Nurse
Trend assessment (shift report)
EdFED- Q

38. At What age do you begin to use logical thought process?
School age childen
Double check equip and patient
Wandering
Fluid volume deficit related to poor intake

39. The order of air flow into the lungs is
Focused
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
Edema
Decreased arterial perfusion

40. The purpose of an intitial assement serves to?
Maslow
Family - spouse - someone other than a healthcare worker - previous medical records.
Assess over all health status and identify the problem
Communicate using hands and eyes.

41. A nursing dx is best described as
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Immature immune system - structures close together lends to easy spreading from on area to another.
Adolescence
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.

42. What is intermittent claudication?
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
Pain in legs assoc w walking
EdFED- Q
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.

43. 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.
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)

44. Nursing interventions should be based on who's theory?
Daily
Maslow
Bacterial infection
Fluid volume deficit related to poor intake

45. The assessment that includes the patient's overhall health status
Broncial (heard over trachea)
Paradoxical reaction
Level of stress - risk for violence - anxiety level - patient unmet needs
Initial assessment

46. Data from the last 24/48 hours that included patterns would be a part of
Nursing dx
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
To ID the problem
Trend assessment (shift report)

47. What are the components of an assessment?
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
Ask - Believe - Choose - Deliver - Empower
Paradoxical reaction

48. What is the difference between hallucination and delirium?
Medical
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts

49. When performing an interview with a patient with vision loss - select the correct questions for obtaining an accurate vision history
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Level of stress - risk for violence - anxiety level - patient unmet needs
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Broncial (heard over trachea)

50. What is the purpose of the nursing process?
Pain
Serves to expedite dx and tx of actual and potential health problems
Implementation
Toddler