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Nursing Fundamentals 3

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Answer 50 questions in 15 minutes.
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Match each statement with the correct term.
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1. Another term for a focused assessment is
Nurse
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Ongoing assessment

2. Ageusia is
ID'ing status of exisiting problems and locating new issues
Loss of taste
Toddler
The result is accurate patient dB

3. Where can wheezes best be heard?
School age childen
Double check equip and patient
Upper airways
Fluid volume deficit related to poor intake

4. The order of air flow into the lungs is
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
Hemoglobin
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Pt's with oxygenation and perfusion problems

5. Nursing dx provides basis of
Focused
Irregular respirations (fast/slow) often seen at end of life
Interventions for which the nurse is accountable
Ask - Believe - Choose - Deliver - Empower

6. Nursing interventions should be based on who's theory?
Interventions for which the nurse is accountable
To simulate eating motions with the hands
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Maslow

7. Examples of personal information
Disorganized thinking and altered LOC
Nursing dx
Nursing
Hygeine - DOB - work hx

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

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9. An example of a secondary source is
Secondary soureces (family - friends)
Maslow
Family - spouse - someone other than a healthcare worker - previous medical records.
Data collection - data validation - data organization - data analysis - and data reporting/recording.

10. Types of hearing loss include
The process of storing - learning - retrieving - and using info.
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
A false - fixed belief that cannot be corrected through reasoning.
Loss of taste

11. Other factors that may indicate confusion using the CAM tool could be
Symptoms
Disorganized thinking and altered LOC
Fluid volume deficit related to poor intake
Capillaries

12. Which patient would be most likely to experience sensory overload?
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Nursing
An 80 y/o patient that has emergency surgery
Trend assessment (shift report)

13. Would a nursing dx be part of the primary or secondary dx?
Assess over all health status and identify the problem
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
Secondary
The process of storing - learning - retrieving - and using info.

14. The path of blood from the heart to the lungs is
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
To ID the problem
Fluid volume deficit related to poor intake

15. What are Cheyne Stokes?
Wandering
Decision assessment
Irregular respirations (fast/slow) often seen at end of life
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts

16. What are the components of an assessment?
Viral infection
Focused
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Data collection - data validation - data organization - data analysis - and data reporting/recording.

17. When speaking with a patient with moderate hearing loss the RN should
Pain
School age childen
Pain in legs assoc w walking
Communicate using hands and eyes.

18. Why are young children at greater risk for respiratory infection?
To simulate eating motions with the hands
Immature immune system - structures close together lends to easy spreading from on area to another.
Hemoglobin
Decreased sense of taste

19. What does CAM stand for
Toddler
Abstract thinking
Confusion Assessment Method
Double check equip and patient

20. What is intermittent claudication?
Pain in legs assoc w walking
Ongoing assessment
Nursing
Double check equip and patient

21. Acceptable sources of assessment data when evaluating a confused patient would be
Secondary soureces (family - friends)
Pain on inspiration and expiration; superficial squeaking or grating
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
Loss of taste

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

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23. Data validation assures
Abstract thinking
The result is accurate patient dB
Pain in legs assoc w walking
Family - spouse - someone other than a healthcare worker - previous medical records.

24. Subjective data could include
Symptoms
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Wandering

25. What is the nursing process?
A false - fixed belief that cannot be corrected through reasoning.
Medical
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.

26. The site where gas exchange occurs is
Adolescence
Assess over all health status and identify the problem
Fast and deep respirations seen in patient's with acidosis
Capillaries

27. 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 -
Loss of taste
Focused
Vesicular (peripheral lung areas)

28. What are the steps of the nursing process?
Preschool is cause and effect - school age begins to use logical thought process.
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Hygeine - DOB - work hx
Symptoms

29. A nursing dx is best described as
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
Irregular respirations (fast/slow) often seen at end of life
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Abstract thinking

30. Hypogeusis is
The patient
Decreased sense of taste
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Preschool is cause and effect - school age begins to use logical thought process.

31. At What age do you begin to put thoughts into words?
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Toddler
Secondary soureces (family - friends)
Interventions for which the nurse is accountable

32. Fluid volume deficit is a __________ dx
Nursing dx
Nursing
The patient
Hemoglobin

33. Describe the purpose of a mental status exam
To simulate eating motions with the hands
Snap - crackle - pops; velcro - bubble wrap
Edema
Defining a baseline of cognitive function - any changes or deviations from norm.

34. Data from the last 24/48 hours that included patterns would be a part of
Trend assessment (shift report)
Immature immune system - structures close together lends to easy spreading from on area to another.
Communicate using hands and eyes.
Decision assessment

35. What factors may indicate plural rub?
Fast and deep respirations seen in patient's with acidosis
Pain on inspiration and expiration; superficial squeaking or grating
Pt's underlying feelings
Maslow

36. QUESTT is a tool for What type of an assessment?
ID'ing status of exisiting problems and locating new issues
Pain
Abstract thinking
Upper airways

37. 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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38. What is pain?
A personal experience that does whatever the person in pain says it does
Defining a baseline of cognitive function - any changes or deviations from norm.
Loss of taste
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)

39. Orthopnea is described as?
Decision assessment
Having to use more than one pillow when sleeping
Inattention and acute increase/decrease in cognitive function
Level of stress - risk for violence - anxiety level - patient unmet needs

40. What is a chochlear implant?
Disorganized thinking and altered LOC
Objective
Interventions for which the nurse is accountable
Surgically implanted device for deaf or hard or hearing - also called bionic ear.

41. Side effects of putting confused pts in restraints include
Sensory motor
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Confusion Assessment Method
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy

42. The path of blood from the lungs to the heart is
Upper airways
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Nursing

43. The fifth vital sign is
Communicate using hands and eyes.
Having to use more than one pillow when sleeping
Secondary
Pain

44. One way to test a person's cognitive ability and abstract thinking ability would be to
The process of storing - learning - retrieving - and using info.
Have them do simple math problems
# of packs per day x # of years smoked
Symptoms

45. An example of a primary source is
Immature immune system - structures close together lends to easy spreading from on area to another.
Preschool is cause and effect - school age begins to use logical thought process.
Pt's with oxygenation and perfusion problems
The patient

46. What are the components of a mental status exam that are not part of a regular assessment?
Nursing dx
Fast and deep respirations seen in patient's with acidosis
Bacterial infection
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances

47. When using restraints in a confused patient
Stroke volume x's heart rate
Risk of falls increases
Abstract thinking
Having to use more than one pillow when sleeping

48. What is the cognitive difference between a preschooler and schoolage child?
Wandering
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Preschool is cause and effect - school age begins to use logical thought process.
To simulate eating motions with the hands

49. What would cause changes in congitive development later in life (middle adulthood)?
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Paradoxical reaction
To simulate eating motions with the hands
Trauma or illness

50. What is the difference between a nursing dx and a med dx?
Initial assessment
Paradoxical reaction
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
A false - fixed belief that cannot be corrected through reasoning.

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Nursing Fundamentals 3

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