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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 What age do you begin to use logical thought process?
Nursing dx
Hygeine - DOB - work hx
School age childen
The process of storing - learning - retrieving - and using info.

2. A potential adverse rx of chemically restraining a confused patient would be
ID'ing status of exisiting problems and locating new issues
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Paradoxical reaction
Disorganized thinking and altered LOC

3. Another term for a focused assessment is
# of packs per day x # of years smoked
Preschool is cause and effect - school age begins to use logical thought process.
EdFED- Q
Ongoing assessment

4. Nursing interventions should be based on who's theory?
Daily
Maslow
Inattention and acute increase/decrease in cognitive function
Nurse

5. Name the 5 'W's' of assessing a change in LOC
Paradoxical reaction
Broncial (heard over trachea)
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
The result is accurate patient dB

6. What is the formula for determining pack years?
# of packs per day x # of years smoked
Loss of taste
Implementation
Wandering

7. An ongoing assessment is performed
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Daily
EdFED- Q
Decision assessment

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)
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Nursing
Trend assessment (shift report)

9. When performing an ongoing assessment for a patient with disturbed thinking the nurse should be sure to include
Sensory motor
Wandering
Level of stress - risk for violence - anxiety level - patient unmet needs
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.

10. What are the steps of the nursing process?
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Nurse
Pt's with oxygenation and perfusion problems
Snap - crackle - pops; velcro - bubble wrap

11. What is the difference between a nursing dx and a med dx?
Symptoms
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Hygeine - DOB - work hx
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.

12. 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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13. Asking a patient what would you do if there is a fire in the wastebasket - is a way to assess their
Paradoxical reaction
8.4
Abstract thinking
Pt's with oxygenation and perfusion problems

14. Expiration sounds are heard longer than inspiration In What area?
To ID the problem
Broncial (heard over trachea)
Confusion Assessment Method
Objective

15. What does CAM stand for
A personal experience that does whatever the person in pain says it does
The result is accurate patient dB
# of packs per day x # of years smoked
Confusion Assessment Method

16. Subjective data could include
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Symptoms
Initial assessment
Objective

17. What would cause changes in congitive development later in life (middle adulthood)?
Pain in legs assoc w walking
Broncial (heard over trachea)
Trauma or illness
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy

18. If an abnormal finding is revealed during assessment - the nurse should
Viral infection
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Double check equip and patient
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)

19. Acceptable sources of assessment data when evaluating a confused patient would be
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Stroke volume x's heart rate
Secondary soureces (family - friends)
# of packs per day x # of years smoked

20. What do rhonchi sound like?
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Interventions for which the nurse is accountable

21. An example of a primary source is
The result is accurate patient dB
The patient
Fast and deep respirations seen in patient's with acidosis
Paradoxical reaction

22. Other factors that may indicate confusion using the CAM tool could be
Disorganized thinking and altered LOC
Upper airways
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
Assess over all health status and identify the problem

23. A patient that is easily fatigued may have a HgB lab value of?
No
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
8.4
Non - opiod (ex: NSAID/acetominaphen)

24. At What age do you begin to use decision making?
A false - fixed belief that cannot be corrected through reasoning.
Adolescence
ID'ing status of exisiting problems and locating new issues
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital

25. Diabetes is a _________ dx
Medical
Decision assessment
Capillaries
ID'ing status of exisiting problems and locating new issues

26. At patient that state their shoes are tighter at the end of the day may be experiencing
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Ask - Believe - Choose - Deliver - Empower
Edema
Assess over all health status and identify the problem

27. One way to test a person's cognitive ability and abstract thinking ability would be to
Medical
An 80 y/o patient that has emergency surgery
8.4
Have them do simple math problems

28. Inspiration sounds are heard longer than expiration sounds In What area?
Objective
Vesicular (peripheral lung areas)
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Preschool is cause and effect - school age begins to use logical thought process.

29. The path of blood from the heart to the lungs is
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Trauma or illness
Viral infection
Risk of falls increases

30. In Which part of the nursing process will you find delegation?
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Implementation
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Snap - crackle - pops; velcro - bubble wrap

31. Ongoing assessments are useful in

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32. Keeping patient's belongings - shoes - suitcases and street clothes - etc. out of view are helpful for preventing: wandering?
Double check equip and patient
Wandering
Capillaries
Pt's underlying feelings

33. What are the ABCDE's of pain management?
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
Interventions for which the nurse is accountable
Trauma or illness
Ask - Believe - Choose - Deliver - Empower

34. If patient reports pain of 3 on scale of 0-10 - What is the appropriate class of pain reliever?
Non - opiod (ex: NSAID/acetominaphen)
Serves to expedite dx and tx of actual and potential health problems
Assess over all health status and identify the problem
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.

35. Examples of personal information
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
Having to use more than one pillow when sleeping
Decision assessment
Hygeine - DOB - work hx

36. Two indicators that are REQUIRED for classification via the CAM tool include
Secondary
To ID the problem
School age childen
Inattention and acute increase/decrease in cognitive function

37. Types of hearing loss include
Broncial (heard over trachea)
Focused
The patient
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)

38. The fifth vital sign is
Level of stress - risk for violence - anxiety level - patient unmet needs
An 80 y/o patient that has emergency surgery
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
Pain

39. What is the difference between hallucination and delirium?
Symptoms
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Viral infection
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.

40. Nursing dx provides basis of
Tricuspid - mitral and the aortic
Pt's underlying feelings
Interventions for which the nurse is accountable
Disorganized thinking and altered LOC

41. An example of a nursing dx would be
Paradoxical reaction
Fluid volume deficit related to poor intake
8.4
Risk of falls increases

42. Data that is recorded for an immediate need (code blue or fall) would be included in
Decision assessment
Risk of falls increases
Irregular respirations (fast/slow) often seen at end of life
EdFED- Q

43. What is a component of the cognitive part of critical thinking skills?
Irregular respirations (fast/slow) often seen at end of life
Secondary
Knowing What to do/how to make a decision based upon available data.
Sensory motor

44. What is the purpose of the nursing process?
Serves to expedite dx and tx of actual and potential health problems
Pain in legs assoc w walking
Trend assessment (shift report)
Bacterial infection

45. When noticing a patient with dementia has stopped eating - the RN's first response is?
To simulate eating motions with the hands
Implementation
An 80 y/o patient that has emergency surgery
The process of storing - learning - retrieving - and using info.

46. Hypogeusis is
Defining a baseline of cognitive function - any changes or deviations from norm.
Knowing What to do/how to make a decision based upon available data.
Decreased sense of taste
Symptoms

47. A nursing dx is best described as
The result is accurate patient dB
Symptoms
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
Focused

48. The basis for a plan of care comes for which stage of the nursing process?
Learning - memory and adaptation to stress
Irregular respirations (fast/slow) often seen at end of life
Nursing dx
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)

49. What is the nursing process?
Non - opiod (ex: NSAID/acetominaphen)
Stroke volume x's heart rate
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Implementation

50. Intermittent claudication is caused by?
The result is accurate patient dB
Defining a baseline of cognitive function - any changes or deviations from norm.
Decreased arterial perfusion
Viral infection