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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. A patient that is easily fatigued may have a HgB lab value of?
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
8.4

2. The assessment that includes the patient's overhall health status
Initial assessment
The process of storing - learning - retrieving - and using info.
EdFED- Q
Irregular respirations (fast/slow) often seen at end of life

3. At What age do you begin to put thoughts into words?
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
Toddler
Objective
Double check equip and patient

4. Data gathered via instrumention (pulse ox) is considered
Capillaries
Pt's underlying feelings
Nursing
Objective

5. An infant is in which Paiget stage?
Sensory motor
A personal experience that does whatever the person in pain says it does
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.

6. Types of hearing loss include
Nursing dx
Irregular respirations (fast/slow) often seen at end of life
Knowing What to do/how to make a decision based upon available data.
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)

7. What does CAM stand for
Secondary soureces (family - friends)
Confusion Assessment Method
A false - fixed belief that cannot be corrected through reasoning.
Snap - crackle - pops; velcro - bubble wrap

8. A patient failing to answer questions or displaying a reluctance to participate in group or family activities may be experiencing
Hearing loss
Disorganized thinking and altered LOC
The process of storing - learning - retrieving - and using info.
Pt's with oxygenation and perfusion problems

9. At What age do you begin to use decision making?
Interventions for which the nurse is accountable
Edema
Adolescence
Focused

10. Once a medical dx has been made - who is accountable for the reporting s/s of complications?
Hygeine - DOB - work hx
Stroke volume x's heart rate
Nurse
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)

11. 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.
Pain
Defining a baseline of cognitive function - any changes or deviations from norm.
Bacterial infection

12. At What age do you begin to use logical thought process?
Immature immune system - structures close together lends to easy spreading from on area to another.
Interventions for which the nurse is accountable
School age childen
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve

13. What is intermittent claudication?
Non - opiod (ex: NSAID/acetominaphen)
Pain in legs assoc w walking
Wandering
Hearing loss

14. A nursing dx is best described as
Toddler
Initial assessment
Disorganized thinking and altered LOC
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.

15. The fifth vital sign is
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Pain
Pt's with oxygenation and perfusion problems
Decreased sense of taste

16. What is cognition?
Paradoxical reaction
Pain
The process of storing - learning - retrieving - and using info.
Toddler

17. Are changes in vital signs a reliable indicator of chronic pain?
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
No

18. Intermittent claudication is caused by?
Family - spouse - someone other than a healthcare worker - previous medical records.
Trauma or illness
The medication will not affect the patient's breathing.
Decreased arterial perfusion

19. The order of air flow into the lungs is
Pt's with oxygenation and perfusion problems
Disorganized thinking and altered LOC
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
Abstract thinking

20. The purpose of an intitial assement serves to?
Focused
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Pain in legs assoc w walking
Assess over all health status and identify the problem

21. Asking a patient what would you do if there is a fire in the wastebasket - is a way to assess their
An 80 y/o patient that has emergency surgery
Maslow
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Abstract thinking

22. What is a chochlear implant?
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Fast and deep respirations seen in patient's with acidosis
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Fluid volume deficit related to poor intake

23. Nursing dx provides basis of
Interventions for which the nurse is accountable
Inattention and acute increase/decrease in cognitive function
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Preschool is cause and effect - school age begins to use logical thought process.

24. 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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25. Another term for a focused assessment is
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
Ongoing assessment
Medical
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve

26. Other factors that may indicate confusion using the CAM tool could be
Snap - crackle - pops; velcro - bubble wrap
Disorganized thinking and altered LOC
Risk of falls increases
Nurse

27. What is the purpose of the nursing process?
Adolescence
To ID the problem
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
Serves to expedite dx and tx of actual and potential health problems

28. What are the components of a mental status exam that are not part of a regular assessment?
Pain
Trend assessment (shift report)
Hearing loss
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances

29. Orthopnea is described as?
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
The medication will not affect the patient's breathing.
Having to use more than one pillow when sleeping
The result is accurate patient dB

30. What is responsible for transporting O2 in the blood
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Upper airways
Hemoglobin
Maslow

31. Data that is recorded for an immediate need (code blue or fall) would be included in
Daily
The process of storing - learning - retrieving - and using info.
Decision assessment
Level of stress - risk for violence - anxiety level - patient unmet needs

32. If patient reports pain of 3 on scale of 0-10 - What is the appropriate class of pain reliever?
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Non - opiod (ex: NSAID/acetominaphen)
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Loss of taste

33. What are Cheyne Stokes?
Irregular respirations (fast/slow) often seen at end of life
Sensory motor
Toddler
Objective

34. The purpose of an initial assessment is
Confusion Assessment Method
Disorganized thinking and altered LOC
Level of stress - risk for violence - anxiety level - patient unmet needs
To ID the problem

35. Describe the purpose of a mental status exam
Having to use more than one pillow when sleeping
Defining a baseline of cognitive function - any changes or deviations from norm.
Family - spouse - someone other than a healthcare worker - previous medical records.
Decreased arterial perfusion

36. When using restraints in a confused patient
Viral infection
Level of stress - risk for violence - anxiety level - patient unmet needs
Hearing loss
Risk of falls increases

37. Sleep deprivation can effect
Capillaries
EdFED- Q
Learning - memory and adaptation to stress
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)

38. Where can you hear bronchovesicular breath sounds?
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Trend assessment (shift report)
A false - fixed belief that cannot be corrected through reasoning.

39. In Which part of the nursing process will you find delegation?
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Implementation
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -

40. The path of blood from the heart to the lungs is
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Learning - memory and adaptation to stress
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
The result is accurate patient dB

41. Name the 5 'W's' of assessing a change in LOC
Fast and deep respirations seen in patient's with acidosis
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Serves to expedite dx and tx of actual and potential health problems

42. 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 -
Preschool is cause and effect - school age begins to use logical thought process.
Adolescence
Non - opiod (ex: NSAID/acetominaphen)

43. What factors may indicate plural rub?
Nursing dx
Paradoxical reaction
Pain on inspiration and expiration; superficial squeaking or grating
Eye hygeine - accomodating factors - what was the level of decline - how long has it been

44. What is a component of the cognitive part of critical thinking skills?
Hearing loss
Trend assessment (shift report)
Knowing What to do/how to make a decision based upon available data.
Fluid volume deficit related to poor intake

45. Diabetes is a _________ dx
Double check equip and patient
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Medical
Vesicular (peripheral lung areas)

46. What is a definition of a delusion?
A false - fixed belief that cannot be corrected through reasoning.
Nursing
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
# of packs per day x # of years smoked

47. Subjective data could include
EdFED- Q
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
Symptoms
Nursing dx

48. Hypogeusis is
Daily
Decreased sense of taste
Capillaries
Ask - Believe - Choose - Deliver - Empower

49. An example of a secondary source is
Family - spouse - someone other than a healthcare worker - previous medical records.
Decreased arterial perfusion
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
Pain in legs assoc w walking

50. Ageusia is
Nursing dx
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
# of packs per day x # of years smoked
Loss of taste