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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. Ongoing assessments are useful in

2. Describe the purpose of a mental status exam
Knowing What to do/how to make a decision based upon available data.
Serves to expedite dx and tx of actual and potential health problems
A personal experience that does whatever the person in pain says it does
Defining a baseline of cognitive function - any changes or deviations from norm.

3. The path of blood from the heart to the lungs is
Having to use more than one pillow when sleeping
Trend assessment (shift report)
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.

4. Where can wheezes best be heard?
Irregular respirations (fast/slow) often seen at end of life
Knowing What to do/how to make a decision based upon available data.
Upper airways
To ID the problem

5. When a patient has increased neutrophils - this may indicate what?
Hearing loss
Pain in legs assoc w walking
Pain
Bacterial infection

6. In Which part of the nursing process will you find delegation?
Implementation
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Having to use more than one pillow when sleeping
Level of stress - risk for violence - anxiety level - patient unmet needs

7. The path of blood from the lungs to the heart is
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Non - opiod (ex: NSAID/acetominaphen)
Nurse

8. Data validation assures
Bacterial infection
The result is accurate patient dB
Symptoms
Knowing What to do/how to make a decision based upon available data.

9. Nursing dx provides basis of
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Interventions for which the nurse is accountable
Fluid volume deficit related to poor intake
Nursing dx

10. Inspiration sounds are heard longer than expiration sounds In What area?
Medical
Non - opiod (ex: NSAID/acetominaphen)
Communicate using hands and eyes.
Vesicular (peripheral lung areas)

11. A patient that is easily fatigued may have a HgB lab value of?
Maslow
Double check equip and patient
Nursing
8.4

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

13. Kussamaul respirations describe

14. Which patient would be most likely to experience sensory overload?
Fluid volume deficit related to poor intake
An 80 y/o patient that has emergency surgery
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
A personal experience that does whatever the person in pain says it does

15. Why are young children at greater risk for respiratory infection?
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Immature immune system - structures close together lends to easy spreading from on area to another.
Defining a baseline of cognitive function - any changes or deviations from norm.
Hemoglobin

16. What would cause changes in congitive development later in life (middle adulthood)?
Stroke volume x's heart rate
Trend assessment (shift report)
Level of stress - risk for violence - anxiety level - patient unmet needs
Trauma or illness

17. What is the nursing process?
Edema
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
School age childen

18. Data gathered via instrumention (pulse ox) is considered
Objective
Sensory motor
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Decreased arterial perfusion

19. When a patient has increased lymphocytes - this may indicate what?
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Viral infection
ID'ing status of exisiting problems and locating new issues
Abstract thinking

20. If an abnormal finding is revealed during assessment - the nurse should
Double check equip and patient
Have them do simple math problems
Nurse
Symptoms

21. What is the correct approach when dealing with older adults?
Viral infection
Upper airways
Toddler
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response

22. The basis for a plan of care comes for which stage of the nursing process?
Disorganized thinking and altered LOC
The process of storing - learning - retrieving - and using info.
Nursing dx
Symptoms

23. What factors may indicate plural rub?
Pain on inspiration and expiration; superficial squeaking or grating
Defining a baseline of cognitive function - any changes or deviations from norm.
Wandering
Confusion Assessment Method

24. Intermittent claudication is caused by?
Decreased arterial perfusion
Pain
Tricuspid - mitral and the aortic
Hearing loss

25. What is the difference between hallucination and delirium?
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Immature immune system - structures close together lends to easy spreading from on area to another.
Double check equip and patient

26. Orthopnea is described as?
Having to use more than one pillow when sleeping
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)

27. Other factors that may indicate confusion using the CAM tool could be
Fluid volume deficit related to poor intake
School age childen
Disorganized thinking and altered LOC
Interventions for which the nurse is accountable

28. An ongoing assessment is performed
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Daily
Preschool is cause and effect - school age begins to use logical thought process.
Confusion Assessment Method

29. One way to test a person's cognitive ability and abstract thinking ability would be to
Serves to expedite dx and tx of actual and potential health problems
Have them do simple math problems
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
An 80 y/o patient that has emergency surgery

30. The assessment that includes the patient's overhall health status
EdFED- Q
Focused
Medical
Initial assessment

31. What is pain?
Abstract thinking
A personal experience that does whatever the person in pain says it does
Communicate using hands and eyes.
Snap - crackle - pops; velcro - bubble wrap

32. At What age do you begin to use logical thought process?
An 80 y/o patient that has emergency surgery
Knowing What to do/how to make a decision based upon available data.
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
School age childen

33. The fifth vital sign is
Ongoing assessment
EdFED- Q
Double check equip and patient
Pain

34. What is the formula for cardiac output?

35. Would a nursing dx be part of the primary or secondary dx?
Focused
Capillaries
Secondary
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.

36. At What age do you begin to use decision making?
Adolescence
Medical
Symptoms
Learning - memory and adaptation to stress

37. When using restraints in a confused patient
# of packs per day x # of years smoked
A false - fixed belief that cannot be corrected through reasoning.
Risk of falls increases
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital

38. What are Piaget's stages of cognitive development
Implementation
8.4
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
Defining a baseline of cognitive function - any changes or deviations from norm.

39. What are the steps of the nursing process?
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Immature immune system - structures close together lends to easy spreading from on area to another.
Interventions for which the nurse is accountable
The patient

40. Blood passes through the heart valves In what order?
The patient
Tricuspid - mitral and the aortic
To simulate eating motions with the hands
8.4

41. All body system data is not necessary which type of assessment
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Focused
Inattention and acute increase/decrease in cognitive function
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy

42. What does CAM stand for
Risk of falls increases
Confusion Assessment Method
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Immature immune system - structures close together lends to easy spreading from on area to another.

43. Hypogeusis is
An 80 y/o patient that has emergency surgery
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Decreased sense of taste

44. Name the 5 'W's' of assessing a change in LOC
Tricuspid - mitral and the aortic
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
The patient

45. Diabetes is a _________ dx
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Decreased arterial perfusion
Trauma or illness
Medical

46. What scale is used to determine eating and feeding issues in adults with confusion
A false - fixed belief that cannot be corrected through reasoning.
Pain
A personal experience that does whatever the person in pain says it does
EdFED- Q

47. The purpose of an initial assessment is
To ID the problem
Toddler
Family - spouse - someone other than a healthcare worker - previous medical records.
Trauma or illness

48. What are the components of a mental status exam that are not part of a regular assessment?
Pain in legs assoc w walking
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Fluid volume deficit related to poor intake

49. When speaking with a patient with moderate hearing loss the RN should
Communicate using hands and eyes.
Knowing What to do/how to make a decision based upon available data.
Wandering
Sensory motor

50. At patient that state their shoes are tighter at the end of the day may be experiencing
Decreased arterial perfusion
Fluid volume deficit related to poor intake
Edema
Loss of taste