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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. When performing an ongoing assessment for a patient with disturbed thinking the nurse should be sure to include
Having to use more than one pillow when sleeping
Level of stress - risk for violence - anxiety level - patient unmet needs
The patient
Confusion Assessment Method

2. The path of blood from the lungs to the heart is
Ask - Believe - Choose - Deliver - Empower
Toddler
Viral infection
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve

3. What is intermittent claudication?
Pain in legs assoc w walking
Snap - crackle - pops; velcro - bubble wrap
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)

4. Data that is recorded for an immediate need (code blue or fall) would be included in
To ID the problem
Pain
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
Decision assessment

5. Data gathered via instrumention (pulse ox) is considered
8.4
Objective
Daily
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts

6. What is a definition of a delusion?
Assess over all health status and identify the problem
Daily
Upper airways
A false - fixed belief that cannot be corrected through reasoning.

7. An infant is in which Paiget stage?
Inattention and acute increase/decrease in cognitive function
Disorganized thinking and altered LOC
Maslow
Sensory motor

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

9. What do rales sound like?
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Hearing loss
Snap - crackle - pops; velcro - bubble wrap

10. Another term for a focused assessment is
The medication will not affect the patient's breathing.
Pain on inspiration and expiration; superficial squeaking or grating
Ongoing assessment
Pain

11. What do rhonchi sound like?
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Initial assessment
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
EdFED- Q

12. The purpose of an intitial assement serves to?
EdFED- Q
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
Assess over all health status and identify the problem
Abstract thinking

13. Subjective data could include
Wandering
Symptoms
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -

14. At What age do you begin to put thoughts into words?
Toddler
# of packs per day x # of years smoked
Abstract thinking
Risk of falls increases

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

16. QUESTT is a tool for What type of an assessment?
Pain
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Tricuspid - mitral and the aortic
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli

17. Describe the purpose of a mental status exam
Defining a baseline of cognitive function - any changes or deviations from norm.
Ask - Believe - Choose - Deliver - Empower
Decision assessment
School age childen

18. Examples of personal information
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
Edema
Hygeine - DOB - work hx

19. Would a nursing dx be part of the primary or secondary dx?
Secondary
Ask - Believe - Choose - Deliver - Empower
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
Decreased sense of taste

20. A potential adverse rx of chemically restraining a confused patient would be
Objective
School age childen
Paradoxical reaction
Loss of taste

21. The assessment that includes the patient's overhall health status
Initial assessment
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Trauma or illness
Fluid volume deficit related to poor intake

22. At patient that state their shoes are tighter at the end of the day may be experiencing
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Edema
Irregular respirations (fast/slow) often seen at end of life

23. What factors may indicate plural rub?
Toddler
Pain on inspiration and expiration; superficial squeaking or grating
A false - fixed belief that cannot be corrected through reasoning.
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.

24. Two indicators that are REQUIRED for classification via the CAM tool include
Viral infection
Having to use more than one pillow when sleeping
Serves to expedite dx and tx of actual and potential health problems
Inattention and acute increase/decrease in cognitive function

25. What is the purpose of the nursing process?
Bacterial infection
A personal experience that does whatever the person in pain says it does
Hearing loss
Serves to expedite dx and tx of actual and potential health problems

26. Where can you hear bronchovesicular breath sounds?
Secondary
Snap - crackle - pops; velcro - bubble wrap
Serves to expedite dx and tx of actual and potential health problems
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.

27. Other factors that may indicate confusion using the CAM tool could be
Pain
Secondary
Disorganized thinking and altered LOC
EdFED- Q

28. An ongoing assessment is performed
Having to use more than one pillow when sleeping
Daily
Inattention and acute increase/decrease in cognitive function
Loss of taste

29. Nursing interventions should be based on who's theory?
Maslow
Hemoglobin
Nurse
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins

30. Ongoing assessments are useful in

31. Once a medical dx has been made - who is accountable for the reporting s/s of complications?
Daily
Have them do simple math problems
Nurse
Objective

32. What are the steps of the nursing process?
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Focused
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Hemoglobin

33. What would cause changes in congitive development later in life (middle adulthood)?
The medication will not affect the patient's breathing.
The process of storing - learning - retrieving - and using info.
Hearing loss
Trauma or illness

34. Asking a patient what would you do if there is a fire in the wastebasket - is a way to assess their
Decreased sense of taste
Abstract thinking
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Assess over all health status and identify the problem

35. What is responsible for transporting O2 in the blood
Hemoglobin
ID'ing status of exisiting problems and locating new issues
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)

36. What is a component of the cognitive part of critical thinking skills?
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
Serves to expedite dx and tx of actual and potential health problems
Having to use more than one pillow when sleeping
Knowing What to do/how to make a decision based upon available data.

37. An example of a secondary source is
Family - spouse - someone other than a healthcare worker - previous medical records.
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Decreased arterial perfusion
Pain

38. Sleep deprivation can effect
Disorganized thinking and altered LOC
Learning - memory and adaptation to stress
Fluid volume deficit related to poor intake
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation

39. One way to test a person's cognitive ability and abstract thinking ability would be to
Have them do simple math problems
Viral infection
Disorganized thinking and altered LOC
School age childen

40. Which patient would be most likely to experience sensory overload?
The patient
Ongoing assessment
An 80 y/o patient that has emergency surgery
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -

41. Inspiration sounds are heard longer than expiration sounds In What area?
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Vesicular (peripheral lung areas)
Level of stress - risk for violence - anxiety level - patient unmet needs
Edema

42. The purpose of an initial assessment is
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Adolescence
To ID the problem
Risk of falls increases

43. What are the ABCDE's of pain management?
Decision assessment
Ask - Believe - Choose - Deliver - Empower
Nurse
A personal experience that does whatever the person in pain says it does

44. What are the components of an assessment?
The patient
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Bacterial infection

45. At What age do you begin to use decision making?
Adolescence
Pain in legs assoc w walking
# of packs per day x # of years smoked
Pain

46. What are Piaget's stages of cognitive development
Bacterial infection
Level of stress - risk for violence - anxiety level - patient unmet needs
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
Sensory motor

47. When performing an interview with a patient with vision loss - select the correct questions for obtaining an accurate vision history
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
The result is accurate patient dB
Wandering
Eye hygeine - accomodating factors - what was the level of decline - how long has it been

48. A patient that is easily fatigued may have a HgB lab value of?
Bacterial infection
8.4
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
The result is accurate patient dB

49. What scale is used to determine eating and feeding issues in adults with confusion
Secondary soureces (family - friends)
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Implementation
EdFED- Q

50. If an abnormal finding is revealed during assessment - the nurse should
Have them do simple math problems
Secondary soureces (family - friends)
Double check equip and patient
Ongoing assessment