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Nursing Fundamentals 3

Instructions:

Answer 50 questions in 15 minutes.
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Match each statement with the correct term.
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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 the correct approach when dealing with older adults?
Tricuspid - mitral and the aortic
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Have them do simple math problems

2. The assessment that includes the patient's overhall health status
Serves to expedite dx and tx of actual and potential health problems
The patient
Initial assessment
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.

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

4. What is the difference between a nursing dx and a med dx?
Disorganized thinking and altered LOC
No
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital

5. What is the cognitive difference between a preschooler and schoolage child?
Edema
Toddler
Preschool is cause and effect - school age begins to use logical thought process.
Ongoing assessment

6. Data gathered via instrumention (pulse ox) is considered
Ongoing assessment
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Objective
Eye hygeine - accomodating factors - what was the level of decline - how long has it been

7. If patient reports pain of 3 on scale of 0-10 - What is the appropriate class of pain reliever?
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Non - opiod (ex: NSAID/acetominaphen)
Stroke volume x's heart rate
Tricuspid - mitral and the aortic

8. Diabetes is a _________ dx
Snap - crackle - pops; velcro - bubble wrap
Initial assessment
Medical
Level of stress - risk for violence - anxiety level - patient unmet needs

9. What do rhonchi sound like?
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
Wandering
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Snap - crackle - pops; velcro - bubble wrap

10. Expiration sounds are heard longer than inspiration In What area?
Broncial (heard over trachea)
Defining a baseline of cognitive function - any changes or deviations from norm.
Have them do simple math problems
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins

11. An example of a secondary source is
Immature immune system - structures close together lends to easy spreading from on area to another.
Capillaries
Family - spouse - someone other than a healthcare worker - previous medical records.
Hygeine - DOB - work hx

12. Describe the purpose of a mental status exam
Viral infection
Pt's underlying feelings
Defining a baseline of cognitive function - any changes or deviations from norm.
Vesicular (peripheral lung areas)

13. Ageusia is
Sensory motor
Symptoms
Loss of taste
Nursing

14. What are the ABCDE's of pain management?
Pain
Symptoms
Ask - Believe - Choose - Deliver - Empower
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital

15. Ongoing assessments are useful in

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16. 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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17. At patient that state their shoes are tighter at the end of the day may be experiencing
Tricuspid - mitral and the aortic
Hearing loss
To simulate eating motions with the hands
Edema

18. Data validation assures
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Family - spouse - someone other than a healthcare worker - previous medical records.
The result is accurate patient dB
8.4

19. Blood passes through the heart valves In what order?
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Focused
Tricuspid - mitral and the aortic
To ID the problem

20. What is a chochlear implant?
Pt's with oxygenation and perfusion problems
Double check equip and patient
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Risk of falls increases

21. At What age do you begin to use logical thought process?
Sensory motor
Trauma or illness
School age childen
Immature immune system - structures close together lends to easy spreading from on area to another.

22. A potential adverse rx of chemically restraining a confused patient would be
Nurse
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
8.4
Paradoxical reaction

23. What is the nursing process?
A false - fixed belief that cannot be corrected through reasoning.
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Decreased arterial perfusion
Implementation

24. At What age do you begin to use decision making?
Irregular respirations (fast/slow) often seen at end of life
Adolescence
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Decreased sense of taste

25. Why are young children at greater risk for respiratory infection?
Immature immune system - structures close together lends to easy spreading from on area to another.
School age childen
8.4
Fast and deep respirations seen in patient's with acidosis

26. What are Piaget's stages of cognitive development
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
Wandering
Decision assessment
Hearing loss

27. What is a definition of a delusion?
Wandering
A false - fixed belief that cannot be corrected through reasoning.
Focused
Loss of taste

28. Two indicators that are REQUIRED for classification via the CAM tool include
Edema
Upper airways
Inattention and acute increase/decrease in cognitive function
The process of storing - learning - retrieving - and using info.

29. An example of a nursing dx would be
Symptoms
Fluid volume deficit related to poor intake
Decreased sense of taste
The medication will not affect the patient's breathing.

30. If an abnormal finding is revealed during assessment - the nurse should
Sensory motor
Double check equip and patient
No
Medical

31. Once a medical dx has been made - who is accountable for the reporting s/s of complications?
Nurse
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Nursing dx
Double check equip and patient

32. In Which part of the nursing process will you find delegation?
Implementation
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Non - opiod (ex: NSAID/acetominaphen)
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)

33. What is responsible for transporting O2 in the blood
The patient
Hemoglobin
Hygeine - DOB - work hx
Pain

34. When noticing a patient with dementia has stopped eating - the RN's first response is?
Confusion Assessment Method
To simulate eating motions with the hands
Pt's with oxygenation and perfusion problems
Eye hygeine - accomodating factors - what was the level of decline - how long has it been

35. What is a component of the cognitive part of critical thinking skills?
Symptoms
Secondary
Knowing What to do/how to make a decision based upon available data.
Family - spouse - someone other than a healthcare worker - previous medical records.

36. What are the steps of the nursing process?
Vesicular (peripheral lung areas)
Pt's with oxygenation and perfusion problems
Sensory motor
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation

37. When using restraints in a confused patient
Pain
Risk of falls increases
Decreased sense of taste
Wandering

38. Intermittent claudication is caused by?
Symptoms
Stroke volume x's heart rate
Broncial (heard over trachea)
Decreased arterial perfusion

39. An infant is in which Paiget stage?
Sensory motor
Fast and deep respirations seen in patient's with acidosis
Have them do simple math problems
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response

40. What do rales sound like?
Level of stress - risk for violence - anxiety level - patient unmet needs
Tricuspid - mitral and the aortic
Snap - crackle - pops; velcro - bubble wrap
EdFED- Q

41. Types of hearing loss include
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)
Inattention and acute increase/decrease in cognitive function
Decreased sense of taste

42. What are Cheyne Stokes?
Medical
To simulate eating motions with the hands
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
Irregular respirations (fast/slow) often seen at end of life

43. The order of air flow into the lungs is
Nurse
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)

44. A patient that is easily fatigued may have a HgB lab value of?
The result is accurate patient dB
Risk of falls increases
8.4
Decreased sense of taste

45. Fluid volume deficit is a __________ dx
Daily
Nursing
Broncial (heard over trachea)
A false - fixed belief that cannot be corrected through reasoning.

46. Which patient would be most likely to experience sensory overload?
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Secondary soureces (family - friends)
An 80 y/o patient that has emergency surgery
Surgically implanted device for deaf or hard or hearing - also called bionic ear.

47. All body system data is not necessary which type of assessment
Symptoms
Tricuspid - mitral and the aortic
Daily
Focused

48. Inspiration sounds are heard longer than expiration sounds In What area?
Vesicular (peripheral lung areas)
Serves to expedite dx and tx of actual and potential health problems
Interventions for which the nurse is accountable
Hearing loss

49. Sleep deprivation can effect
Learning - memory and adaptation to stress
8.4
Fluid volume deficit related to poor intake
Initial assessment

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

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Nursing Fundamentals 3

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