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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. Data gathered via instrumention (pulse ox) is considered
Level of stress - risk for violence - anxiety level - patient unmet needs
Tricuspid - mitral and the aortic
Objective
Preschool is cause and effect - school age begins to use logical thought process.

2. What is a definition of a delusion?
Maslow
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
Pain

3. What are Cheyne Stokes?
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Irregular respirations (fast/slow) often seen at end of life
The patient
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -

4. Diabetes is a _________ dx
Nurse
Viral infection
Medical
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response

5. Types of hearing loss include
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
Learning - memory and adaptation to stress
Level of stress - risk for violence - anxiety level - patient unmet needs
Family - spouse - someone other than a healthcare worker - previous medical records.

6. The assessment that includes the patient's overhall health status
Toddler
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Confusion Assessment Method
Initial assessment

7. Subjective data could include
Fast and deep respirations seen in patient's with acidosis
Symptoms
Snap - crackle - pops; velcro - bubble wrap
Having to use more than one pillow when sleeping

8. A nursing dx is best described as
Bacterial infection
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
Broncial (heard over trachea)
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.

9. What does CAM stand for
Abstract thinking
Trauma or illness
Preschool is cause and effect - school age begins to use logical thought process.
Confusion Assessment Method

10. When a patient has increased neutrophils - this may indicate what?
Hemoglobin
Wandering
Upper airways
Bacterial infection

11. Nursing interventions should be based on who's theory?
Maslow
Viral infection
Fast and deep respirations seen in patient's with acidosis
To ID the problem

12. 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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13. Ongoing assessments are useful in

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14. When performing an ongoing assessment for a patient with disturbed thinking the nurse should be sure to include
Sensory motor
Inattention and acute increase/decrease in cognitive function
Pt's with oxygenation and perfusion problems
Level of stress - risk for violence - anxiety level - patient unmet needs

15. Sleep deprivation can effect
Snap - crackle - pops; velcro - bubble wrap
Having to use more than one pillow when sleeping
Secondary
Learning - memory and adaptation to stress

16. Which patient would be most likely to experience sensory overload?
ID'ing status of exisiting problems and locating new issues
Have them do simple math problems
An 80 y/o patient that has emergency surgery
Pt's with oxygenation and perfusion problems

17. If patient reports pain of 3 on scale of 0-10 - What is the appropriate class of pain reliever?
Knowing What to do/how to make a decision based upon available data.
To ID the problem
Snap - crackle - pops; velcro - bubble wrap
Non - opiod (ex: NSAID/acetominaphen)

18. Data that is recorded for an immediate need (code blue or fall) would be included in
Pt's with oxygenation and perfusion problems
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
To ID the problem
Decision assessment

19. Intermittent claudication is caused by?
Defining a baseline of cognitive function - any changes or deviations from norm.
Wandering
Bacterial infection
Decreased arterial perfusion

20. What do rales sound like?
EdFED- Q
The patient
Defining a baseline of cognitive function - any changes or deviations from norm.
Snap - crackle - pops; velcro - bubble wrap

21. Orthopnea is described as?
To ID the problem
A false - fixed belief that cannot be corrected through reasoning.
Having to use more than one pillow when sleeping
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve

22. What is the difference between hallucination and delirium?
Objective
Ongoing assessment
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Implementation

23. Are changes in vital signs a reliable indicator of chronic pain?
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Vesicular (peripheral lung areas)
No
Tricuspid - mitral and the aortic

24. In Which part of the nursing process will you find delegation?
Non - opiod (ex: NSAID/acetominaphen)
The result is accurate patient dB
Fast and deep respirations seen in patient's with acidosis
Implementation

25. Inspiration sounds are heard longer than expiration sounds In What area?
Irregular respirations (fast/slow) often seen at end of life
Snap - crackle - pops; velcro - bubble wrap
Decision assessment
Vesicular (peripheral lung areas)

26. What are Piaget's stages of cognitive development
Assess over all health status and identify the problem
ID'ing status of exisiting problems and locating new issues
Interventions for which the nurse is accountable
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)

27. The path of blood from the heart to the lungs is
Daily
Risk of falls increases
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Level of stress - risk for violence - anxiety level - patient unmet needs

28. All body system data is not necessary which type of assessment
Focused
An 80 y/o patient that has emergency surgery
Wandering
Surgically implanted device for deaf or hard or hearing - also called bionic ear.

29. Expiration sounds are heard longer than inspiration In What area?
Learning - memory and adaptation to stress
A personal experience that does whatever the person in pain says it does
Broncial (heard over trachea)
Daily

30. The purpose of an intitial assement serves to?
Initial assessment
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Assess over all health status and identify the problem
Paradoxical reaction

31. Fluid volume deficit is a __________ dx
Hemoglobin
Secondary soureces (family - friends)
Family - spouse - someone other than a healthcare worker - previous medical records.
Nursing

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
To simulate eating motions with the hands
Abstract thinking
# of packs per day x # of years smoked

33. What is the purpose of the nursing process?
A false - fixed belief that cannot be corrected through reasoning.
Serves to expedite dx and tx of actual and potential health problems
8.4
Family - spouse - someone other than a healthcare worker - previous medical records.

34. Where can you hear bronchovesicular breath sounds?
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Hygeine - DOB - work hx
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
Irregular respirations (fast/slow) often seen at end of life

35. Would a nursing dx be part of the primary or secondary dx?
Fluid volume deficit related to poor intake
The patient
Secondary
Data collection - data validation - data organization - data analysis - and data reporting/recording.

36. When using restraints in a confused patient
Risk of falls increases
Assess over all health status and identify the problem
Initial assessment
Serves to expedite dx and tx of actual and potential health problems

37. Side effects of putting confused pts in restraints include
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Tricuspid - mitral and the aortic
Double check equip and patient
ID'ing status of exisiting problems and locating new issues

38. What are the components of an assessment?
Decreased sense of taste
Ongoing assessment
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Maslow

39. Where can wheezes best be heard?
Snap - crackle - pops; velcro - bubble wrap
Maslow
Pt's with oxygenation and perfusion problems
Upper airways

40. Keeping patient's belongings - shoes - suitcases and street clothes - etc. out of view are helpful for preventing: wandering?
Wandering
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
Symptoms

41. Blood passes through the heart valves In what order?
ID'ing status of exisiting problems and locating new issues
Immature immune system - structures close together lends to easy spreading from on area to another.
Implementation
Tricuspid - mitral and the aortic

42. What is a chochlear implant?
Nursing dx
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.
Decision assessment

43. An example of a nursing dx would be
Fluid volume deficit related to poor intake
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Non - opiod (ex: NSAID/acetominaphen)
Viral infection

44. 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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45. Name the 5 'W's' of assessing a change in LOC
Pain in legs assoc w walking
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Fast and deep respirations seen in patient's with acidosis
Broncial (heard over trachea)

46. The path of blood from the lungs to the heart is
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Maslow
Nurse
Implementation

47. Acceptable sources of assessment data when evaluating a confused patient would be
Decreased sense of taste
Secondary soureces (family - friends)
Edema
Nursing dx

48. At What age do you begin to use logical thought process?
To simulate eating motions with the hands
Upper airways
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
School age childen

49. A patient failing to answer questions or displaying a reluctance to participate in group or family activities may be experiencing
Hearing loss
Pain in legs assoc w walking
Trend assessment (shift report)
Initial assessment

50. What are the steps of the nursing process?
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
Double check equip and patient
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Preschool is cause and effect - school age begins to use logical thought process.