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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. Nursing interventions should be based on who's theory?
Hemoglobin
Adolescence
Paradoxical reaction
Maslow

2. What are the components of an assessment?
Irregular respirations (fast/slow) often seen at end of life
Initial assessment
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Focused

3. What is cognition?
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
The process of storing - learning - retrieving - and using info.
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Having to use more than one pillow when sleeping

4. What are Cheyne Stokes?
Secondary soureces (family - friends)
Irregular respirations (fast/slow) often seen at end of life
Confusion Assessment Method
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)

5. What is the correct approach when dealing with older adults?
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Pain
Disorganized thinking and altered LOC
Decreased arterial perfusion

6. Which patient would be most likely to experience sensory overload?
An 80 y/o patient that has emergency surgery
Pain on inspiration and expiration; superficial squeaking or grating
Viral infection
Risk of falls increases

7. Kussamaul respirations describe

8. What is the formula for determining pack years?
A false - fixed belief that cannot be corrected through reasoning.
Confusion Assessment Method
# of packs per day x # of years smoked
Eye hygeine - accomodating factors - what was the level of decline - how long has it been

9. Data gathered via instrumention (pulse ox) is considered
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Maslow
Objective
Viral infection

10. Would a nursing dx be part of the primary or secondary dx?
Secondary
Wandering
Implementation
Edema

11. All body system data is not necessary which type of assessment
The patient
Focused
Trend assessment (shift report)
Paradoxical reaction

12. Fluid volume deficit is a __________ dx
Nursing
Objective
Paradoxical reaction
Pain

13. Blood passes through the heart valves In what order?
Implementation
Trauma or illness
Tricuspid - mitral and the aortic
Nurse

14. What are the steps of the nursing process?
To simulate eating motions with the hands
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Adolescence
Toddler

15. Side effects of putting confused pts in restraints include
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Communicate using hands and eyes.
Surgically implanted device for deaf or hard or hearing - also called bionic ear.

16. Data from the last 24/48 hours that included patterns would be a part of
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Trend assessment (shift report)
Ask - Believe - Choose - Deliver - Empower
Defining a baseline of cognitive function - any changes or deviations from norm.

17. Sleep deprivation can effect
Learning - memory and adaptation to stress
Decreased arterial perfusion
Sensory motor
Medical

18. When a patient has increased neutrophils - this may indicate what?
Preschool is cause and effect - school age begins to use logical thought process.
Bacterial infection
The process of storing - learning - retrieving - and using info.
Level of stress - risk for violence - anxiety level - patient unmet needs

19. What is intermittent claudication?
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Pain in legs assoc w walking
Hearing loss
Learning - memory and adaptation to stress

20. If an abnormal finding is revealed during assessment - the nurse should
Adolescence
ID'ing status of exisiting problems and locating new issues
EdFED- Q
Double check equip and patient

21. Diabetes is a _________ dx
Sensory motor
Knowing What to do/how to make a decision based upon available data.
A false - fixed belief that cannot be corrected through reasoning.
Medical

22. What are Piaget's stages of cognitive development
Edema
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
Trend assessment (shift report)
Disorganized thinking and altered LOC

23. What is a chochlear implant?
Inattention and acute increase/decrease in cognitive function
Snap - crackle - pops; velcro - bubble wrap
Loss of taste
Surgically implanted device for deaf or hard or hearing - also called bionic ear.

24. The path of blood from the lungs to the heart is
Non - opiod (ex: NSAID/acetominaphen)
School age childen
Abstract thinking
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve

25. Acceptable sources of assessment data when evaluating a confused patient would be
Maslow
Secondary
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Secondary soureces (family - friends)

26. The assessment that includes the patient's overhall health status
Decision assessment
Decreased arterial perfusion
Initial assessment
ID'ing status of exisiting problems and locating new issues

27. Where can you hear bronchovesicular breath sounds?
8.4
Initial assessment
An 80 y/o patient that has emergency surgery
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.

28. Are changes in vital signs a reliable indicator of chronic pain?
Non - opiod (ex: NSAID/acetominaphen)
No
Vesicular (peripheral lung areas)
Trend assessment (shift report)

29. What are the components of a mental status exam that are not part of a regular assessment?
Defining a baseline of cognitive function - any changes or deviations from norm.
Edema
Having to use more than one pillow when sleeping
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances

30. Once a medical dx has been made - who is accountable for the reporting s/s of complications?
Abstract thinking
Having to use more than one pillow when sleeping
Nurse
The patient

31. At What age do you begin to use logical thought process?
School age childen
Disorganized thinking and altered LOC
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Confusion Assessment Method

32. The purpose of an intitial assement serves to?
A false - fixed belief that cannot be corrected through reasoning.
Bacterial infection
Capillaries
Assess over all health status and identify the problem

33. At What age do you begin to use decision making?
Adolescence
Learning - memory and adaptation to stress
Having to use more than one pillow when sleeping
# of packs per day x # of years smoked

34. Examples of personal information
A false - fixed belief that cannot be corrected through reasoning.
Hygeine - DOB - work hx
Ongoing assessment
Secondary

35. What is the purpose of the nursing process?
The process of storing - learning - retrieving - and using info.
Risk of falls increases
Serves to expedite dx and tx of actual and potential health problems
Broncial (heard over trachea)

36. Ageusia is
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
The patient
Bacterial infection
Loss of taste

37. What scale is used to determine eating and feeding issues in adults with confusion
EdFED- Q
Disorganized thinking and altered LOC
Nursing
Tricuspid - mitral and the aortic

38. Another term for a focused assessment is
Decreased sense of taste
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
Wandering
Ongoing assessment

39. The fifth vital sign is
To simulate eating motions with the hands
Pain
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
Vesicular (peripheral lung areas)

40. Describe the purpose of a mental status exam
Broncial (heard over trachea)
Vesicular (peripheral lung areas)
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
Defining a baseline of cognitive function - any changes or deviations from norm.

41. 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.
Sensory motor
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Double check equip and patient

42. When a patient has increased lymphocytes - this may indicate what?
Nursing dx
Viral infection
School age childen
Defining a baseline of cognitive function - any changes or deviations from norm.

43. What is a definition of a delusion?
A false - fixed belief that cannot be corrected through reasoning.
Secondary
Hemoglobin
Learning - memory and adaptation to stress

44. Inspiration sounds are heard longer than expiration sounds In What area?
A personal experience that does whatever the person in pain says it does
Vesicular (peripheral lung areas)
Tricuspid - mitral and the aortic
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)

45. What is responsible for transporting O2 in the blood
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Hemoglobin
Pain
Secondary soureces (family - friends)

46. When noticing a patient with dementia has stopped eating - the RN's first response is?
The process of storing - learning - retrieving - and using info.
Symptoms
To simulate eating motions with the hands
Implementation

47. What is the cognitive difference between a preschooler and schoolage child?
Preschool is cause and effect - school age begins to use logical thought process.
Interventions for which the nurse is accountable
Nursing
Fast and deep respirations seen in patient's with acidosis

48. An example of a primary source is
Paradoxical reaction
The patient
Objective
The process of storing - learning - retrieving - and using info.

49. Orthopnea is described as?
Confusion Assessment Method
Having to use more than one pillow when sleeping
Loss of taste
Double check equip and patient

50. Other factors that may indicate confusion using the CAM tool could be
Irregular respirations (fast/slow) often seen at end of life
Disorganized thinking and altered LOC
A false - fixed belief that cannot be corrected through reasoning.
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve