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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. What is intermittent claudication?
Pain in legs assoc w walking
Capillaries
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.

2. The assessment that includes the patient's overhall health status
Defining a baseline of cognitive function - any changes or deviations from norm.
Double check equip and patient
Initial assessment
Paradoxical reaction

3. The order of air flow into the lungs is
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
EdFED- Q
Hearing loss
Pain on inspiration and expiration; superficial squeaking or grating

4. What are the components of a mental status exam that are not part of a regular assessment?
Disorganized thinking and altered LOC
Hemoglobin
A false - fixed belief that cannot be corrected through reasoning.
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances

5. When noticing a patient with dementia has stopped eating - the RN's first response is?
Focused
To simulate eating motions with the hands
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Inattention and acute increase/decrease in cognitive function

6. Side effects of putting confused pts in restraints include
Fluid volume deficit related to poor intake
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Family - spouse - someone other than a healthcare worker - previous medical records.

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

8. Expiration sounds are heard longer than inspiration In What area?
Secondary
The process of storing - learning - retrieving - and using info.
Broncial (heard over trachea)
Initial assessment

9. What are the steps of the nursing process?
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
School age childen
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Bacterial infection

10. Nursing dx provides basis of
Upper airways
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
Interventions for which the nurse is accountable
Knowing What to do/how to make a decision based upon available data.

11. Ageusia is
Secondary
Loss of taste
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
Ask - Believe - Choose - Deliver - Empower

12. When speaking with a patient with moderate hearing loss the RN should
Communicate using hands and eyes.
Disorganized thinking and altered LOC
Inattention and acute increase/decrease in cognitive function
Viral infection

13. Nursing interventions should be based on who's theory?
Maslow
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Hygeine - DOB - work hx
The medication will not affect the patient's breathing.

14. What is a component of the cognitive part of critical thinking skills?
Capillaries
ID'ing status of exisiting problems and locating new issues
Knowing What to do/how to make a decision based upon available data.
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -

15. The purpose of an initial assessment is
Maslow
To ID the problem
Nursing dx
Daily

16. When using restraints in a confused patient
8.4
No
Defining a baseline of cognitive function - any changes or deviations from norm.
Risk of falls increases

17. When performing an ongoing assessment for a patient with disturbed thinking the nurse should be sure to include
Pain
Pt's underlying feelings
Level of stress - risk for violence - anxiety level - patient unmet needs
Nursing

18. Diabetes is a _________ dx
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Tricuspid - mitral and the aortic
Medical
Risk of falls increases

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

20. Data from the last 24/48 hours that included patterns would be a part of
Pain
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Capillaries
Trend assessment (shift report)

21. Kussamaul respirations describe

22. What is the nursing process?
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Snap - crackle - pops; velcro - bubble wrap
Disorganized thinking and altered LOC
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)

23. What factors may indicate plural rub?
The medication will not affect the patient's breathing.
Pain on inspiration and expiration; superficial squeaking or grating
Objective
Nursing

24. Fluid volume deficit is a __________ dx
Interventions for which the nurse is accountable
Tricuspid - mitral and the aortic
Inattention and acute increase/decrease in cognitive function
Nursing

25. What is a chochlear implant?
Implementation
To ID the problem
Snap - crackle - pops; velcro - bubble wrap
Surgically implanted device for deaf or hard or hearing - also called bionic ear.

26. Intermittent claudication is caused by?
Interventions for which the nurse is accountable
Decreased arterial perfusion
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Pt's with oxygenation and perfusion problems

27. One way to test a person's cognitive ability and abstract thinking ability would be to
School age childen
ID'ing status of exisiting problems and locating new issues
Have them do simple math problems
Hemoglobin

28. What is the correct approach when dealing with older adults?
Objective
Initial assessment
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
School age childen

29. Where can wheezes best be heard?
Upper airways
Sensory motor
Disorganized thinking and altered LOC
Snap - crackle - pops; velcro - bubble wrap

30. What does CAM stand for
Confusion Assessment Method
No
Family - spouse - someone other than a healthcare worker - previous medical records.
Hearing loss

31. What are Cheyne Stokes?
Double check equip and patient
Irregular respirations (fast/slow) often seen at end of life
Paradoxical reaction
Defining a baseline of cognitive function - any changes or deviations from norm.

32. The basis for a plan of care comes for which stage of the nursing process?
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
Nursing dx
Initial assessment
Daily

33. Ongoing assessments are useful in

34. What is the cognitive difference between a preschooler and schoolage child?
Preschool is cause and effect - school age begins to use logical thought process.
An 80 y/o patient that has emergency surgery
Decreased sense of taste
Hygeine - DOB - work hx

35. The site where gas exchange occurs is
Objective
A personal experience that does whatever the person in pain says it does
Capillaries
The process of storing - learning - retrieving - and using info.

36. Subjective data could include
Abstract thinking
Knowing What to do/how to make a decision based upon available data.
Symptoms
Paradoxical reaction

37. 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
Adolescence
Viral infection
Having to use more than one pillow when sleeping

38. The purpose of an intitial assement serves to?
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
ID'ing status of exisiting problems and locating new issues
Implementation
Assess over all health status and identify the problem

39. What are the components of an assessment?
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Medical
# of packs per day x # of years smoked
Data collection - data validation - data organization - data analysis - and data reporting/recording.

40. What is pain?
A personal experience that does whatever the person in pain says it does
Loss of taste
Viral infection
Initial assessment

41. What are the ABCDE's of pain management?
Ask - Believe - Choose - Deliver - Empower
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
Immature immune system - structures close together lends to easy spreading from on area to another.
Fluid volume deficit related to poor intake

42. A potential adverse rx of chemically restraining a confused patient would be
Paradoxical reaction
Fast and deep respirations seen in patient's with acidosis
Disorganized thinking and altered LOC
Capillaries

43. An ongoing assessment is performed
Double check equip and patient
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Daily
An 80 y/o patient that has emergency surgery

44. Acceptable sources of assessment data when evaluating a confused patient would be
Decreased sense of taste
EdFED- Q
Decreased arterial perfusion
Secondary soureces (family - friends)

45. Are changes in vital signs a reliable indicator of chronic pain?
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
No
Immature immune system - structures close together lends to easy spreading from on area to another.
Implementation

46. Once a medical dx has been made - who is accountable for the reporting s/s of complications?
Ongoing assessment
Nurse
Initial assessment
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve

47. What is responsible for transporting O2 in the blood
Hemoglobin
Fast and deep respirations seen in patient's with acidosis
Decreased sense of taste
Pain on inspiration and expiration; superficial squeaking or grating

48. What is the formula for cardiac output?

49. Other factors that may indicate confusion using the CAM tool could be
Bacterial infection
Focused
Disorganized thinking and altered LOC
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances

50. Types of hearing loss include
Fast and deep respirations seen in patient's with acidosis
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
Pt's underlying feelings
A personal experience that does whatever the person in pain says it does