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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. Another term for a focused assessment is
Ongoing assessment
Maslow
Nursing dx
Knowing What to do/how to make a decision based upon available data.

2. The purpose of an initial assessment is
A personal experience that does whatever the person in pain says it does
Have them do simple math problems
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
To ID the problem

3. The fifth vital sign is
The patient
Serves to expedite dx and tx of actual and potential health problems
Pain
8.4

4. Diabetes is a _________ dx
Paradoxical reaction
Pain in legs assoc w walking
No
Medical

5. What would cause changes in congitive development later in life (middle adulthood)?
Medical
Abstract thinking
Viral infection
Trauma or illness

6. The assessment that includes the patient's overhall health status
Pain
Initial assessment
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
Have them do simple math problems

7. Asking a patient what would you do if there is a fire in the wastebasket - is a way to assess their
Hygeine - DOB - work hx
Abstract thinking
Hearing loss
Secondary

8. All body system data is not necessary which type of assessment
School age childen
Daily
Loss of taste
Focused

9. What are the components of a mental status exam that are not part of a regular assessment?
Nursing dx
Interventions for which the nurse is accountable
Broncial (heard over trachea)
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances

10. What is the cognitive difference between a preschooler and schoolage child?
Pain on inspiration and expiration; superficial squeaking or grating
Preschool is cause and effect - school age begins to use logical thought process.
Level of stress - risk for violence - anxiety level - patient unmet needs
Objective

11. At patient that state their shoes are tighter at the end of the day may be experiencing
Pain
Pain in legs assoc w walking
Edema
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)

12. Hypogeusis is
Preschool is cause and effect - school age begins to use logical thought process.
Maslow
Decreased sense of taste
The process of storing - learning - retrieving - and using info.

13. What is a definition of a delusion?
Irregular respirations (fast/slow) often seen at end of life
A false - fixed belief that cannot be corrected through reasoning.
Disorganized thinking and altered LOC
The process of storing - learning - retrieving - and using info.

14. What scale is used to determine eating and feeding issues in adults with confusion
The result is accurate patient dB
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
EdFED- Q

15. Inspiration sounds are heard longer than expiration sounds In What area?
Learning - memory and adaptation to stress
Initial assessment
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Vesicular (peripheral lung areas)

16. Keeping patient's belongings - shoes - suitcases and street clothes - etc. out of view are helpful for preventing: wandering?
Have them do simple math problems
Wandering
Medical
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances

17. Two indicators that are REQUIRED for classification via the CAM tool include
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Inattention and acute increase/decrease in cognitive function
Pt's with oxygenation and perfusion problems
Broncial (heard over trachea)

18. What is the formula for cardiac output?

19. One way to test a person's cognitive ability and abstract thinking ability would be to
Assess over all health status and identify the problem
Have them do simple math problems
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Knowing What to do/how to make a decision based upon available data.

20. At What age do you begin to use decision making?
Preschool is cause and effect - school age begins to use logical thought process.
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Adolescence

21. What are the ABCDE's of pain management?
Ask - Believe - Choose - Deliver - Empower
A false - fixed belief that cannot be corrected through reasoning.
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
Risk of falls increases

22. An example of a secondary source is
Family - spouse - someone other than a healthcare worker - previous medical records.
A personal experience that does whatever the person in pain says it does
A false - fixed belief that cannot be corrected through reasoning.
Risk of falls increases

23. Once a medical dx has been made - who is accountable for the reporting s/s of complications?
Stroke volume x's heart rate
Preschool is cause and effect - school age begins to use logical thought process.
Nurse
Decreased sense of taste

24. What are the steps of the nursing process?
Immature immune system - structures close together lends to easy spreading from on area to another.
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Preschool is cause and effect - school age begins to use logical thought process.
Fluid volume deficit related to poor intake

25. What do rales sound like?
Trend assessment (shift report)
Secondary soureces (family - friends)
Snap - crackle - pops; velcro - bubble wrap
Learning - memory and adaptation to stress

26. Side effects of putting confused pts in restraints include
Knowing What to do/how to make a decision based upon available data.
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Pain in legs assoc w walking
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy

27. An infant is in which Paiget stage?
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
Sensory motor
Hearing loss
Pt's with oxygenation and perfusion problems

28. The path of blood from the heart to the lungs is
Trauma or illness
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Bacterial infection
Nursing

29. A patient that is dying is on morphine. The family is concerned the prs breathing will stop. What is the correct RN response?

30. Intermittent claudication is caused by?
Irregular respirations (fast/slow) often seen at end of life
Communicate using hands and eyes.
Decreased arterial perfusion
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)

31. Factors that may reduce the efficacy of pulse oximetry include
Pain
Pain in legs assoc w walking
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
The medication will not affect the patient's breathing.

32. 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
Hemoglobin
ID'ing status of exisiting problems and locating new issues
A false - fixed belief that cannot be corrected through reasoning.

33. What is the nursing process?
Broncial (heard over trachea)
Trauma or illness
Edema
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.

34. What are Cheyne Stokes?
EdFED- Q
Fluid volume deficit related to poor intake
A false - fixed belief that cannot be corrected through reasoning.
Irregular respirations (fast/slow) often seen at end of life

35. 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.
Implementation
Medical
Focused

36. The purpose of an intitial assement serves to?
Pain on inspiration and expiration; superficial squeaking or grating
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Assess over all health status and identify the problem
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins

37. What is the correct approach when dealing with older adults?
Disorganized thinking and altered LOC
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
To ID the problem
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.

38. Ageusia is
An 80 y/o patient that has emergency surgery
Loss of taste
Nurse
No

39. What is intermittent claudication?
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Pain in legs assoc w walking
Immature immune system - structures close together lends to easy spreading from on area to another.
Toddler

40. Are changes in vital signs a reliable indicator of chronic pain?
The result is accurate patient dB
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Implementation
No

41. What is cognition?
Decreased sense of taste
Edema
Decision assessment
The process of storing - learning - retrieving - and using info.

42. Kussamaul respirations describe

43. The order of air flow into the lungs is
Initial assessment
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
Having to use more than one pillow when sleeping
Trauma or illness

44. Expiration sounds are heard longer than inspiration In What area?
Broncial (heard over trachea)
Double check equip and patient
Pain in legs assoc w walking
Confusion Assessment Method

45. When performing an interview with a patient with vision loss - select the correct questions for obtaining an accurate vision history
Knowing What to do/how to make a decision based upon available data.
Paradoxical reaction
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Broncial (heard over trachea)

46. What is the purpose of the nursing process?
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
Serves to expedite dx and tx of actual and potential health problems
Risk of falls increases

47. Where can wheezes best be heard?
EdFED- Q
Pt's underlying feelings
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
Upper airways

48. The path of blood from the lungs to the heart is
Toddler
Disorganized thinking and altered LOC
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Viral infection

49. When performing an ongoing assessment for a patient with disturbed thinking the nurse should be sure to include
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Initial assessment
Level of stress - risk for violence - anxiety level - patient unmet needs
To simulate eating motions with the hands

50. At What age do you begin to put thoughts into words?
Toddler
Abstract thinking
Ask - Believe - Choose - Deliver - Empower
Double check equip and patient