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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. If an abnormal finding is revealed during assessment - the nurse should
The medication will not affect the patient's breathing.
Double check equip and patient
Disorganized thinking and altered LOC
School age childen

2. What are Piaget's stages of cognitive development
The patient
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
Initial assessment
Trend assessment (shift report)

3. What factors may indicate plural rub?
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
Pain on inspiration and expiration; superficial squeaking or grating
Abstract thinking
The patient

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

5. Data that is recorded for an immediate need (code blue or fall) would be included in
Snap - crackle - pops; velcro - bubble wrap
Focused
Decreased sense of taste
Decision assessment

6. Other factors that may indicate confusion using the CAM tool could be
Disorganized thinking and altered LOC
Double check equip and patient
Pain
Sensory motor

7. What are the components of an assessment?
Nursing dx
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Data collection - data validation - data organization - data analysis - and data reporting/recording.
The process of storing - learning - retrieving - and using info.

8. Factors that may reduce the efficacy of pulse oximetry include
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Paradoxical reaction
Snap - crackle - pops; velcro - bubble wrap
Immature immune system - structures close together lends to easy spreading from on area to another.

9. A patient that is easily fatigued may have a HgB lab value of?
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
8.4
Hearing loss
Pt's with oxygenation and perfusion problems

10. When a patient has increased neutrophils - this may indicate what?
Bacterial infection
Inattention and acute increase/decrease in cognitive function
The process of storing - learning - retrieving - and using info.
Focused

11. QUESTT is a tool for What type of an assessment?
Initial assessment
Pain
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Implementation

12. What is a chochlear implant?
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Risk of falls increases
No

13. What are the components of a mental status exam that are not part of a regular assessment?
8.4
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
Initial assessment

14. The purpose of an intitial assement serves to?
Secondary soureces (family - friends)
Assess over all health status and identify the problem
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
Broncial (heard over trachea)

15. Diabetes is a _________ dx
Secondary soureces (family - friends)
Medical
Learning - memory and adaptation to stress
Communicate using hands and eyes.

16. At What age do you begin to use logical thought process?
School age childen
Edema
Pain in legs assoc w walking
Pain

17. Describe the purpose of a mental status exam
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Defining a baseline of cognitive function - any changes or deviations from norm.
Adolescence
Fast and deep respirations seen in patient's with acidosis

18. 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)
A false - fixed belief that cannot be corrected through reasoning.
Nurse
Pt's underlying feelings

19. Nursing interventions should be based on who's theory?
Abstract thinking
Non - opiod (ex: NSAID/acetominaphen)
Maslow
Secondary

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

21. When noticing a patient with dementia has stopped eating - the RN's first response is?
To simulate eating motions with the hands
Pain
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Level of stress - risk for violence - anxiety level - patient unmet needs

22. What is pain?
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Hemoglobin
Upper airways
A personal experience that does whatever the person in pain says it does

23. An example of a nursing dx would be
Fluid volume deficit related to poor intake
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Inattention and acute increase/decrease in cognitive function
Bacterial infection

24. An example of a secondary source is
A false - fixed belief that cannot be corrected through reasoning.
Hygeine - DOB - work hx
Family - spouse - someone other than a healthcare worker - previous medical records.
Focused

25. Intermittent claudication is caused by?
Nursing
Pt's underlying feelings
Decreased arterial perfusion
Trauma or illness

26. Sleep deprivation can effect
Pt's with oxygenation and perfusion problems
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Learning - memory and adaptation to stress

27. The basis for a plan of care comes for which stage of the nursing process?
8.4
Pain on inspiration and expiration; superficial squeaking or grating
# of packs per day x # of years smoked
Nursing dx

28. The path of blood from the heart to the lungs is
Capillaries
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
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -

29. Subjective data could include
Double check equip and patient
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Symptoms

30. What is cognition?
The process of storing - learning - retrieving - and using info.
Medical
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Nurse

31. What is a definition of a delusion?
Learning - memory and adaptation to stress
Paradoxical reaction
Edema
A false - fixed belief that cannot be corrected through reasoning.

32. The purpose of an initial assessment is
To ID the problem
Hemoglobin
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Nursing dx

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

34. What is the purpose of the nursing process?
Serves to expedite dx and tx of actual and potential health problems
# of packs per day x # of years smoked
Objective
Secondary

35. What is the formula for cardiac output?

36. Where can you hear bronchovesicular breath sounds?
Preschool is cause and effect - school age begins to use logical thought process.
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Vesicular (peripheral lung areas)
Initial assessment

37. What is the difference between a nursing dx and a med dx?
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Fast and deep respirations seen in patient's with acidosis
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital

38. What is a component of the cognitive part of critical thinking skills?
Nursing dx
School age childen
Knowing What to do/how to make a decision based upon available data.
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy

39. Ageusia is
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
# of packs per day x # of years smoked
Loss of taste
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins

40. When performing an interview with a patient with vision loss - select the correct questions for obtaining an accurate vision history
Have them do simple math problems
Hygeine - DOB - work hx
Pain
Eye hygeine - accomodating factors - what was the level of decline - how long has it been

41. When a patient has increased lymphocytes - this may indicate what?
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Edema
Irregular respirations (fast/slow) often seen at end of life
Viral infection

42. Would a nursing dx be part of the primary or secondary dx?
Preschool is cause and effect - school age begins to use logical thought process.
Secondary
Toddler
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts

43. What is the correct approach when dealing with older adults?
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Bacterial infection
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Trauma or illness

44. At What age do you begin to put thoughts into words?
Having to use more than one pillow when sleeping
Tricuspid - mitral and the aortic
Toddler
Bacterial infection

45. A potential adverse rx of chemically restraining a confused patient would be
Trauma or illness
Serves to expedite dx and tx of actual and potential health problems
Paradoxical reaction
Non - opiod (ex: NSAID/acetominaphen)

46. Examples of personal information
A false - fixed belief that cannot be corrected through reasoning.
Broncial (heard over trachea)
Disorganized thinking and altered LOC
Hygeine - DOB - work hx

47. At patient that state their shoes are tighter at the end of the day may be experiencing
Hygeine - DOB - work hx
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Edema

48. What do rales sound like?
Loss of taste
Adolescence
Capillaries
Snap - crackle - pops; velcro - bubble wrap

49. Once a medical dx has been made - who is accountable for the reporting s/s of complications?
Nurse
Loss of taste
Fluid volume deficit related to poor intake
Broncial (heard over trachea)

50. What is the difference between hallucination and delirium?
The patient
To simulate eating motions with the hands
A false - fixed belief that cannot be corrected through reasoning.
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.