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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 a chochlear implant?
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Hemoglobin
Non - opiod (ex: NSAID/acetominaphen)
Immature immune system - structures close together lends to easy spreading from on area to another.

2. Intermittent claudication is caused by?
Abstract thinking
Inattention and acute increase/decrease in cognitive function
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Decreased arterial perfusion

3. The site where gas exchange occurs is
Daily
Hygeine - DOB - work hx
Capillaries
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts

4. Other factors that may indicate confusion using the CAM tool could be
Level of stress - risk for violence - anxiety level - patient unmet needs
Disorganized thinking and altered LOC
Have them do simple math problems
The process of storing - learning - retrieving - and using info.

5. An example of a nursing dx would be
Fluid volume deficit related to poor intake
Learning - memory and adaptation to stress
Daily
Sensory motor

6. ABG's would be an important lab value for What types of patient's?

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7. Side effects of putting confused pts in restraints include
Pt's underlying feelings
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Stroke volume x's heart rate
Family - spouse - someone other than a healthcare worker - previous medical records.

8. What does CAM stand for
Pain on inspiration and expiration; superficial squeaking or grating
Trend assessment (shift report)
Confusion Assessment Method
No

9. Acceptable sources of assessment data when evaluating a confused patient would be
Sensory motor
The process of storing - learning - retrieving - and using info.
Secondary soureces (family - friends)
Vesicular (peripheral lung areas)

10. A potential adverse rx of chemically restraining a confused patient would be
Paradoxical reaction
Double check equip and patient
Immature immune system - structures close together lends to easy spreading from on area to another.
Nursing dx

11. What is the difference between a nursing dx and a med dx?
Symptoms
Inattention and acute increase/decrease in cognitive function
Medical
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital

12. A patient failing to answer questions or displaying a reluctance to participate in group or family activities may be experiencing
Nurse
Hearing loss
Inattention and acute increase/decrease in cognitive function
Double check equip and patient

13. What are the components of an assessment?
Nursing dx
Data collection - data validation - data organization - data analysis - and data reporting/recording.
# of packs per day x # of years smoked
Initial assessment

14. What are the steps of the nursing process?
Broncial (heard over trachea)
Decision assessment
Symptoms
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation

15. At What age do you begin to use logical thought process?
Trauma or illness
School age childen
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Paradoxical reaction

16. Why are young children at greater risk for respiratory infection?
Fluid volume deficit related to poor intake
Knowing What to do/how to make a decision based upon available data.
Loss of taste
Immature immune system - structures close together lends to easy spreading from on area to another.

17. When using restraints in a confused patient
Vesicular (peripheral lung areas)
Risk of falls increases
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
Communicate using hands and eyes.

18. In Which part of the nursing process will you find delegation?
Paradoxical reaction
Implementation
Loss of taste
Level of stress - risk for violence - anxiety level - patient unmet needs

19. Examples of personal information
Hygeine - DOB - work hx
Decision assessment
Pain on inspiration and expiration; superficial squeaking or grating
Data collection - data validation - data organization - data analysis - and data reporting/recording.

20. Describe the purpose of a mental status exam
Nursing dx
Defining a baseline of cognitive function - any changes or deviations from norm.
A personal experience that does whatever the person in pain says it does
Non - opiod (ex: NSAID/acetominaphen)

21. The order of air flow into the lungs is
An 80 y/o patient that has emergency surgery
Have them do simple math problems
Pt's underlying feelings
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli

22. At What age do you begin to put thoughts into words?
8.4
Toddler
Symptoms
Defining a baseline of cognitive function - any changes or deviations from norm.

23. Expiration sounds are heard longer than inspiration In What area?
Pain
Broncial (heard over trachea)
Level of stress - risk for violence - anxiety level - patient unmet needs
Capillaries

24. If patient reports pain of 3 on scale of 0-10 - What is the appropriate class of pain reliever?
Nurse
Have them do simple math problems
Non - opiod (ex: NSAID/acetominaphen)
Daily

25. The purpose of an initial assessment is
Hearing loss
Non - opiod (ex: NSAID/acetominaphen)
Decision assessment
To ID the problem

26. The assessment that includes the patient's overhall health status
Initial assessment
The process of storing - learning - retrieving - and using info.
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 -

27. Two indicators that are REQUIRED for classification via the CAM tool include
Pain
Inattention and acute increase/decrease in cognitive function
Bacterial infection
Pt's with oxygenation and perfusion problems

28. Diabetes is a _________ dx
Nursing dx
Trauma or illness
Medical
Capillaries

29. What would cause changes in congitive development later in life (middle adulthood)?
The patient
Inattention and acute increase/decrease in cognitive function
Trauma or illness
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins

30. A patient that is easily fatigued may have a HgB lab value of?
Inattention and acute increase/decrease in cognitive function
Pt's underlying feelings
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
8.4

31. Are changes in vital signs a reliable indicator of chronic pain?
Have them do simple math problems
Upper airways
Nursing dx
No

32. What is the cognitive difference between a preschooler and schoolage child?
Irregular respirations (fast/slow) often seen at end of life
Preschool is cause and effect - school age begins to use logical thought process.
Decreased arterial perfusion
No

33. Name the 5 'W's' of assessing a change in LOC
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
Vesicular (peripheral lung areas)
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Eye hygeine - accomodating factors - what was the level of decline - how long has it been

34. Data validation assures
8.4
Nurse
The result is accurate patient dB
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response

35. The path of blood from the lungs to the heart is
ID'ing status of exisiting problems and locating new issues
Interventions for which the nurse is accountable
Decreased sense of taste
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve

36. QUESTT is a tool for What type of an assessment?
Pain
The result is accurate patient dB
Confusion Assessment Method
Have them do simple math problems

37. The fifth vital sign is
Pain
Inattention and acute increase/decrease in cognitive function
Toddler
Decision assessment

38. Types of hearing loss include
Upper airways
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
Defining a baseline of cognitive function - any changes or deviations from norm.
Knowing What to do/how to make a decision based upon available data.

39. 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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40. All body system data is not necessary which type of assessment
Focused
Upper airways
Stroke volume x's heart rate
Have them do simple math problems

41. Kussamaul respirations describe

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42. A nursing dx is best described as
Level of stress - risk for violence - anxiety level - patient unmet needs
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
Inattention and acute increase/decrease in cognitive function
Trauma or illness

43. Asking a patient what would you do if there is a fire in the wastebasket - is a way to assess their
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Level of stress - risk for violence - anxiety level - patient unmet needs
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
Abstract thinking

44. What is the formula for determining pack years?
# of packs per day x # of years smoked
Pain
Hemoglobin
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.

45. What is a component of the cognitive part of critical thinking skills?
Snap - crackle - pops; velcro - bubble wrap
Initial assessment
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Knowing What to do/how to make a decision based upon available data.

46. What is intermittent claudication?
Initial assessment
Pain in legs assoc w walking
Level of stress - risk for violence - anxiety level - patient unmet needs
Toddler

47. An example of a secondary source is
Viral infection
Stroke volume x's heart rate
Family - spouse - someone other than a healthcare worker - previous medical records.
Trend assessment (shift report)

48. One way to test a person's cognitive ability and abstract thinking ability would be to
School age childen
Implementation
No
Have them do simple math problems

49. What do rales sound like?
Pain
Snap - crackle - pops; velcro - bubble wrap
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Confusion Assessment Method

50. If an abnormal finding is revealed during assessment - the nurse should
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Wandering
To ID the problem
Double check equip and patient