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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 nursing dx would be
The result is accurate patient dB
Having to use more than one pillow when sleeping
Adolescence
Fluid volume deficit related to poor intake

2. Nursing interventions should be based on who's theory?
Nursing
A personal experience that does whatever the person in pain says it does
Maslow
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy

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

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4. Data validation assures
Decreased sense of taste
Toddler
Hearing loss
The result is accurate patient dB

5. What is the correct approach when dealing with older adults?
Pain
Maslow
Hemoglobin
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response

6. What is the purpose of the nursing process?
Assess over all health status and identify the problem
The patient
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Serves to expedite dx and tx of actual and potential health problems

7. What scale is used to determine eating and feeding issues in adults with confusion
Symptoms
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
EdFED- Q
Defining a baseline of cognitive function - any changes or deviations from norm.

8. Are changes in vital signs a reliable indicator of chronic pain?
Inattention and acute increase/decrease in cognitive function
Family - spouse - someone other than a healthcare worker - previous medical records.
No
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.

9. What is cognition?
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
The process of storing - learning - retrieving - and using info.
Decreased arterial perfusion
Risk of falls increases

10. When performing an ongoing assessment for a patient with disturbed thinking the nurse should be sure to include
The result is accurate patient dB
Level of stress - risk for violence - anxiety level - patient unmet needs
Paradoxical reaction
Pain on inspiration and expiration; superficial squeaking or grating

11. The site where gas exchange occurs is
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Wandering
Capillaries
Pt's underlying feelings

12. In Which part of the nursing process will you find delegation?
Family - spouse - someone other than a healthcare worker - previous medical records.
Adolescence
Serves to expedite dx and tx of actual and potential health problems
Implementation

13. All body system data is not necessary which type of assessment
Irregular respirations (fast/slow) often seen at end of life
Focused
Pain in legs assoc w walking
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)

14. One way to test a person's cognitive ability and abstract thinking ability would be to
Hearing loss
Decision assessment
Have them do simple math problems
The process of storing - learning - retrieving - and using info.

15. What is a chochlear implant?
Daily
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
EdFED- Q

16. What would cause changes in congitive development later in life (middle adulthood)?
ID'ing status of exisiting problems and locating new issues
Double check equip and patient
Edema
Trauma or illness

17. Ageusia is
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Snap - crackle - pops; velcro - bubble wrap
Pain on inspiration and expiration; superficial squeaking or grating
Loss of taste

18. Asking a patient what would you do if there is a fire in the wastebasket - is a way to assess their
Pain
Abstract thinking
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Daily

19. Other factors that may indicate confusion using the CAM tool could be
ID'ing status of exisiting problems and locating new issues
Disorganized thinking and altered LOC
Stroke volume x's heart rate
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts

20. Examples of personal information
Fluid volume deficit related to poor intake
Implementation
Toddler
Hygeine - DOB - work hx

21. Intermittent claudication is caused by?
Snap - crackle - pops; velcro - bubble wrap
Irregular respirations (fast/slow) often seen at end of life
Decreased arterial perfusion
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation

22. Kussamaul respirations describe

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23. At What age do you begin to put thoughts into words?
Implementation
Hygeine - DOB - work hx
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Toddler

24. Subjective data could include
Maslow
Nursing dx
Assess over all health status and identify the problem
Symptoms

25. What is the difference between hallucination and delirium?
Fast and deep respirations seen in patient's with acidosis
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
A personal experience that does whatever the person in pain says it does
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve

26. What is a component of the cognitive part of critical thinking skills?
Pain on inspiration and expiration; superficial squeaking or grating
Knowing What to do/how to make a decision based upon available data.
Risk of falls increases
Decreased sense of taste

27. What is intermittent claudication?
Pain in legs assoc w walking
Hearing loss
Tricuspid - mitral and the aortic
Objective

28. Two indicators that are REQUIRED for classification via the CAM tool include
The patient
Inattention and acute increase/decrease in cognitive function
An 80 y/o patient that has emergency surgery
The medication will not affect the patient's breathing.

29. When a patient has increased neutrophils - this may indicate what?
Bacterial infection
Fluid volume deficit related to poor intake
The process of storing - learning - retrieving - and using info.
Pt's with oxygenation and perfusion problems

30. The fifth vital sign is
No
Pain
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy

31. If an abnormal finding is revealed during assessment - the nurse should
Double check equip and patient
Assess over all health status and identify the problem
School age childen
Knowing What to do/how to make a decision based upon available data.

32. The basis for a plan of care comes for which stage of the nursing process?
No
Confusion Assessment Method
Nursing dx
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response

33. Once a medical dx has been made - who is accountable for the reporting s/s of complications?
Inattention and acute increase/decrease in cognitive function
ID'ing status of exisiting problems and locating new issues
Secondary
Nurse

34. What does CAM stand for
Family - spouse - someone other than a healthcare worker - previous medical records.
Confusion Assessment Method
Double check equip and patient
Preschool is cause and effect - school age begins to use logical thought process.

35. If patient reports pain of 3 on scale of 0-10 - What is the appropriate class of pain reliever?
Inattention and acute increase/decrease in cognitive function
ID'ing status of exisiting problems and locating new issues
Non - opiod (ex: NSAID/acetominaphen)
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli

36. The order of air flow into the lungs is
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
An 80 y/o patient that has emergency surgery
Ask - Believe - Choose - Deliver - Empower
Toddler

37. The purpose of an initial assessment is
Wandering
To ID the problem
Decreased sense of taste
Pt's with oxygenation and perfusion problems

38. Sleep deprivation can effect
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Pain
Learning - memory and adaptation to stress
Trend assessment (shift report)

39. What is the formula for cardiac output?

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40. Types of hearing loss include
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
The result is accurate patient dB
Nursing dx
Hemoglobin

41. Data that is recorded for an immediate need (code blue or fall) would be included in
Decision assessment
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Snap - crackle - pops; velcro - bubble wrap
ID'ing status of exisiting problems and locating new issues

42. 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
The process of storing - learning - retrieving - and using info.
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Decreased arterial perfusion

43. When noticing a patient with dementia has stopped eating - the RN's first response is?
To simulate eating motions with the hands
Trauma or illness
Disorganized thinking and altered LOC
Have them do simple math problems

44. What is the cognitive difference between a preschooler and schoolage child?
Decreased arterial perfusion
Preschool is cause and effect - school age begins to use logical thought process.
Fluid volume deficit related to poor intake
Trauma or illness

45. A potential adverse rx of chemically restraining a confused patient would be
Paradoxical reaction
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
8.4

46. What are the components of an assessment?
Preschool is cause and effect - school age begins to use logical thought process.
Immature immune system - structures close together lends to easy spreading from on area to another.
Pt's underlying feelings
Data collection - data validation - data organization - data analysis - and data reporting/recording.

47. Where can wheezes best be heard?
Tricuspid - mitral and the aortic
Wandering
Upper airways
The patient

48. What are the steps of the nursing process?
Pain on inspiration and expiration; superficial squeaking or grating
School age childen
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation

49. What do rhonchi sound like?
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Family - spouse - someone other than a healthcare worker - previous medical records.
Paradoxical reaction
Sensory motor

50. Fluid volume deficit is a __________ dx
ID'ing status of exisiting problems and locating new issues
No
Symptoms
Nursing