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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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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. Other factors that may indicate confusion using the CAM tool could be
Disorganized thinking and altered LOC
Vesicular (peripheral lung areas)
Fluid volume deficit related to poor intake
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation

2. What does CAM stand for
To ID the problem
Nursing
Confusion Assessment Method
School age childen

3. What is responsible for transporting O2 in the blood
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Tricuspid - mitral and the aortic
EdFED- Q
Hemoglobin

4. Intermittent claudication is caused by?
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Pt's underlying feelings
Decreased arterial perfusion
No

5. In Which part of the nursing process will you find delegation?
Pain
Hygeine - DOB - work hx
Decreased sense of taste
Implementation

6. When a patient has increased neutrophils - this may indicate what?
Hemoglobin
Bacterial infection
Objective
Vesicular (peripheral lung areas)

7. What is the correct approach when dealing with older adults?
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
Hearing loss
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
# of packs per day x # of years smoked

8. Diabetes is a _________ dx
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Edema
Serves to expedite dx and tx of actual and potential health problems
Medical

9. Acceptable sources of assessment data when evaluating a confused patient would be
Secondary soureces (family - friends)
Ongoing assessment
To ID the problem
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -

10. What is the purpose of the nursing process?
# of packs per day x # of years smoked
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Serves to expedite dx and tx of actual and potential health problems
Paradoxical reaction

11. What do rhonchi sound like?
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Edema
Symptoms

12. An example of a secondary source is
Vesicular (peripheral lung areas)
Daily
Family - spouse - someone other than a healthcare worker - previous medical records.
Focused

13. The assessment that includes the patient's overhall health status
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Initial assessment
Symptoms
Immature immune system - structures close together lends to easy spreading from on area to another.

14. Orthopnea is described as?
Snap - crackle - pops; velcro - bubble wrap
Non - opiod (ex: NSAID/acetominaphen)
Pt's underlying feelings
Having to use more than one pillow when sleeping

15. The purpose of an initial assessment is
Confusion Assessment Method
Trend assessment (shift report)
The medication will not affect the patient's breathing.
To ID the problem

16. All body system data is not necessary which type of assessment
Nurse
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Nursing
Focused

17. Name the 5 'W's' of assessing a change in LOC
Disorganized thinking and altered LOC
An 80 y/o patient that has emergency surgery
A false - fixed belief that cannot be corrected through reasoning.
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)

18. 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.
Family - spouse - someone other than a healthcare worker - previous medical records.
Irregular respirations (fast/slow) often seen at end of life

19. The path of blood from the lungs to the heart is
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Irregular respirations (fast/slow) often seen at end of life
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve

20. Once a medical dx has been made - who is accountable for the reporting s/s of complications?
Hearing loss
The process of storing - learning - retrieving - and using info.
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Nurse

21. The site where gas exchange occurs is
Capillaries
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Trauma or illness

22. What scale is used to determine eating and feeding issues in adults with confusion
Tricuspid - mitral and the aortic
Double check equip and patient
EdFED- Q
Viral infection

23. What is a definition of a delusion?
Abstract thinking
A false - fixed belief that cannot be corrected through reasoning.
Family - spouse - someone other than a healthcare worker - previous medical records.
Serves to expedite dx and tx of actual and potential health problems

24. What are Piaget's stages of cognitive development
Capillaries
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
Double check equip and patient
Ongoing assessment

25. A nursing dx is best described as
Daily
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
Pain on inspiration and expiration; superficial squeaking or grating
Pain in legs assoc w walking

26. The fifth vital sign is
Pain
School age childen
Pain in legs assoc w walking
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins

27. 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
Pain on inspiration and expiration; superficial squeaking or grating
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Decreased sense of taste

28. Where can you hear bronchovesicular breath sounds?
Edema
8.4
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Maslow

29. At What age do you begin to use logical thought process?
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
School age childen
# of packs per day x # of years smoked
The medication will not affect the patient's breathing.

30. What is cognition?
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)
Decreased sense of taste
Secondary

31. QUESTT is a tool for What type of an assessment?
Risk of falls increases
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Medical
Pain

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
Immature immune system - structures close together lends to easy spreading from on area to another.
Abstract thinking
Non - opiod (ex: NSAID/acetominaphen)

33. What is the difference between a nursing dx and a med dx?
Family - spouse - someone other than a healthcare worker - previous medical records.
Implementation
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Viral infection

34. Factors that may reduce the efficacy of pulse oximetry include
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Stroke volume x's heart rate
Preschool is cause and effect - school age begins to use logical thought process.

35. Fluid volume deficit is a __________ dx
Nursing
Immature immune system - structures close together lends to easy spreading from on area to another.
Viral infection
# of packs per day x # of years smoked

36. What is the difference between hallucination and delirium?
Snap - crackle - pops; velcro - bubble wrap
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Toddler

37. What would cause changes in congitive development later in life (middle adulthood)?
Initial assessment
Trauma or illness
Hygeine - DOB - work hx
Nurse

38. 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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39. The basis for a plan of care comes for which stage of the nursing process?
Stroke volume x's heart rate
Nursing dx
Symptoms
Pt's underlying feelings

40. Examples of personal information
Hygeine - DOB - work hx
Nursing
Serves to expedite dx and tx of actual and potential health problems
Surgically implanted device for deaf or hard or hearing - also called bionic ear.

41. Another term for a focused assessment is
Level of stress - risk for violence - anxiety level - patient unmet needs
Loss of taste
Ongoing assessment
Nurse

42. What is pain?
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Assess over all health status and identify the problem
A personal experience that does whatever the person in pain says it does
A false - fixed belief that cannot be corrected through reasoning.

43. At patient that state their shoes are tighter at the end of the day may be experiencing
Edema
Pt's with oxygenation and perfusion problems
Pain on inspiration and expiration; superficial squeaking or grating
Learning - memory and adaptation to stress

44. Expiration sounds are heard longer than inspiration In What area?
Serves to expedite dx and tx of actual and potential health problems
Disorganized thinking and altered LOC
Paradoxical reaction
Broncial (heard over trachea)

45. Would a nursing dx be part of the primary or secondary dx?
Secondary
Sensory motor
Double check equip and patient
Adolescence

46. Are changes in vital signs a reliable indicator of chronic pain?
No
Loss of taste
The medication will not affect the patient's breathing.
The patient

47. Data that is recorded for an immediate need (code blue or fall) would be included in
Hygeine - DOB - work hx
Tricuspid - mitral and the aortic
Decision assessment
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances

48. At What age do you begin to use decision making?
ID'ing status of exisiting problems and locating new issues
The process of storing - learning - retrieving - and using info.
Focused
Adolescence

49. Subjective data could include
Symptoms
Snap - crackle - pops; velcro - bubble wrap
Pain
Pain in legs assoc w walking

50. Nursing dx provides basis of
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Interventions for which the nurse is accountable
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Stroke volume x's heart rate

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Nursing Fundamentals 3

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