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Nursing Fundamentals 3

Instructions:

Answer 50 questions in 15 minutes.
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Match each statement with the correct term.
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1. Diabetes is a _________ dx
Medical
Initial assessment
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Broncial (heard over trachea)

2. Fluid volume deficit is a __________ 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
Objective
Nursing

3. Would a nursing dx be part of the primary or secondary dx?
Nurse
Objective
Focused
Secondary

4. At What age do you begin to put thoughts into words?
# of packs per day x # of years smoked
Paradoxical reaction
Toddler
The patient

5. QUESTT is a tool for What type of an assessment?
Adolescence
The patient
EdFED- Q
Pain

6. Once a medical dx has been made - who is accountable for the reporting s/s of complications?
Preschool is cause and effect - school age begins to use logical thought process.
Nurse
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Non - opiod (ex: NSAID/acetominaphen)

7. All body system data is not necessary which type of assessment
Immature immune system - structures close together lends to easy spreading from on area to another.
The result is accurate patient dB
Secondary soureces (family - friends)
Focused

8. What are the components of a mental status exam that are not part of a regular assessment?
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
Bacterial infection
Nurse
To ID the problem

9. Hypogeusis is
Nurse
Decreased sense of taste
Trend assessment (shift report)
Data collection - data validation - data organization - data analysis - and data reporting/recording.

10. What scale is used to determine eating and feeding issues in adults with confusion
EdFED- Q
Objective
Trend assessment (shift report)
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -

11. Blood passes through the heart valves In what order?
Tricuspid - mitral and the aortic
Secondary soureces (family - friends)
Paradoxical reaction
School age childen

12. The fifth vital sign is
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Pain
Pain on inspiration and expiration; superficial squeaking or grating
Double check equip and patient

13. What is the formula for determining pack years?
No
Have them do simple math problems
Decreased arterial perfusion
# of packs per day x # of years smoked

14. When using restraints in a confused patient
Toddler
Hygeine - DOB - work hx
Paradoxical reaction
Risk of falls increases

15. An example of a primary source is
Having to use more than one pillow when sleeping
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Data collection - data validation - data organization - data analysis - and data reporting/recording.
The patient

16. Nursing interventions should be based on who's theory?
Secondary soureces (family - friends)
School age childen
Maslow
Assess over all health status and identify the problem

17. Other factors that may indicate confusion using the CAM tool could be
Non - opiod (ex: NSAID/acetominaphen)
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Disorganized thinking and altered LOC
Secondary soureces (family - friends)

18. What is a component of the cognitive part of critical thinking skills?
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.
Wandering
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.

19. Subjective data could include
Pt's underlying feelings
Bacterial infection
Disorganized thinking and altered LOC
Symptoms

20. The basis for a plan of care comes for which stage of the nursing process?
Nursing dx
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Defining a baseline of cognitive function - any changes or deviations from norm.

21. When performing an interview with a patient with vision loss - select the correct questions for obtaining an accurate vision history
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Paradoxical reaction
Ask - Believe - Choose - Deliver - Empower
Decreased sense of taste

22. Factors that may reduce the efficacy of pulse oximetry include
Disorganized thinking and altered LOC
Focused
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -

23. What is the formula for cardiac output?

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24. What would cause changes in congitive development later in life (middle adulthood)?
Trauma or illness
Maslow
The patient
Snap - crackle - pops; velcro - bubble wrap

25. Two indicators that are REQUIRED for classification via the CAM tool include
Fast and deep respirations seen in patient's with acidosis
Inattention and acute increase/decrease in cognitive function
The medication will not affect the patient's breathing.
Implementation

26. Another term for a focused assessment is
The result is accurate patient dB
Knowing What to do/how to make a decision based upon available data.
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Ongoing assessment

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

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28. An infant is in which Paiget stage?
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Sensory motor
Having to use more than one pillow when sleeping

29. When a patient has increased neutrophils - this may indicate what?
Bacterial infection
Adolescence
Decreased sense of taste
The result is accurate patient dB

30. Ongoing assessments are useful in

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31. The order of air flow into the lungs is
An 80 y/o patient that has emergency surgery
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
Nurse
Daily

32. Ageusia is
Loss of taste
Level of stress - risk for violence - anxiety level - patient unmet needs
Edema
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve

33. What is a chochlear implant?
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
The process of storing - learning - retrieving - and using info.
Broncial (heard over trachea)
Defining a baseline of cognitive function - any changes or deviations from norm.

34. What do rhonchi sound like?
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Have them do simple math problems
Snap - crackle - pops; velcro - bubble wrap

35. 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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36. Sleep deprivation can effect
Pain
Decision assessment
Learning - memory and adaptation to stress
Nursing dx

37. If an abnormal finding is revealed during assessment - the nurse should
Double check equip and patient
Nursing
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
Stroke volume x's heart rate

38. What is the difference between a nursing dx and a med dx?
Assess over all health status and identify the problem
Secondary
Hygeine - DOB - work hx
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital

39. A nursing dx is best described as
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
To simulate eating motions with the hands

40. When performing an ongoing assessment for a patient with disturbed thinking the nurse should be sure to include
Level of stress - risk for violence - anxiety level - patient unmet needs
Pain
Pain in legs assoc w walking
Preschool is cause and effect - school age begins to use logical thought process.

41. Describe the purpose of a mental status exam
Paradoxical reaction
Defining a baseline of cognitive function - any changes or deviations from norm.
Immature immune system - structures close together lends to easy spreading from on area to another.
Pt's with oxygenation and perfusion problems

42. Examples of personal information
Hygeine - DOB - work hx
Pt's underlying feelings
Stroke volume x's heart rate
Snap - crackle - pops; velcro - bubble wrap

43. A patient failing to answer questions or displaying a reluctance to participate in group or family activities may be experiencing
Pt's with oxygenation and perfusion problems
Knowing What to do/how to make a decision based upon available data.
ID'ing status of exisiting problems and locating new issues
Hearing loss

44. Asking a patient what would you do if there is a fire in the wastebasket - is a way to assess their
Initial assessment
Abstract thinking
Nursing
Eye hygeine - accomodating factors - what was the level of decline - how long has it been

45. What are Piaget's stages of cognitive development
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
Adolescence
Broncial (heard over trachea)
Pain

46. The path of blood from the lungs to the heart is
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Knowing What to do/how to make a decision based upon available data.
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Sensory motor

47. An ongoing assessment is performed
Daily
Pain
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Hearing loss

48. A potential adverse rx of chemically restraining a confused patient would be
Risk of falls increases
Paradoxical reaction
The process of storing - learning - retrieving - and using info.
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.

49. If patient reports pain of 3 on scale of 0-10 - What is the appropriate class of pain reliever?
Non - opiod (ex: NSAID/acetominaphen)
Pt's with oxygenation and perfusion problems
Learning - memory and adaptation to stress
Medical

50. A patient that is easily fatigued may have a HgB lab value of?
Toddler
Pain
8.4
Implementation

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Nursing Fundamentals 3

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