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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. Orthopnea is described as?
# of packs per day x # of years smoked
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Focused
Having to use more than one pillow when sleeping

2. What does CAM stand for
Confusion Assessment Method
The medication will not affect the patient's breathing.
Tricuspid - mitral and the aortic
Trend assessment (shift report)

3. Where can you hear bronchovesicular breath sounds?
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Serves to expedite dx and tx of actual and potential health problems

4. What factors may indicate plural rub?
A personal experience that does whatever the person in pain says it does
Pain on inspiration and expiration; superficial squeaking or grating
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Adolescence

5. Nursing dx provides basis of
Objective
Broncial (heard over trachea)
Capillaries
Interventions for which the nurse is accountable

6. What do rales sound like?
Snap - crackle - pops; velcro - bubble wrap
EdFED- Q
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Daily

7. Data validation assures
Trend assessment (shift report)
The result is accurate patient dB
Paradoxical reaction
Irregular respirations (fast/slow) often seen at end of life

8. An example of a primary source is
Decreased sense of taste
Capillaries
Initial assessment
The patient

9. What is the correct approach when dealing with older adults?
Defining a baseline of cognitive function - any changes or deviations from norm.
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Loss of taste
The process of storing - learning - retrieving - and using info.

10. Describe the purpose of a mental status exam
Defining a baseline of cognitive function - any changes or deviations from norm.
The patient
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Nursing dx

11. The basis for a plan of care comes for which stage of the nursing process?
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Nursing dx
Secondary
Maslow

12. The order of air flow into the lungs is
Level of stress - risk for violence - anxiety level - patient unmet needs
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
Assess over all health status and identify the problem
An 80 y/o patient that has emergency surgery

13. Ongoing assessments are useful in

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14. Once a medical dx has been made - who is accountable for the reporting s/s of complications?
Nurse
Preschool is cause and effect - school age begins to use logical thought process.
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Wandering

15. The fifth vital sign is
Pain
Fast and deep respirations seen in patient's with acidosis
Wandering
Decision assessment

16. A patient failing to answer questions or displaying a reluctance to participate in group or family activities may be experiencing
Fluid volume deficit related to poor intake
Hearing loss
Ask - Believe - Choose - Deliver - Empower
School age childen

17. When performing an interview with a patient with vision loss - select the correct questions for obtaining an accurate vision history
Implementation
The process of storing - learning - retrieving - and using info.
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Pt's underlying feelings

18. What would cause changes in congitive development later in life (middle adulthood)?
Immature immune system - structures close together lends to easy spreading from on area to another.
Symptoms
Trauma or illness
Pt's underlying feelings

19. At What age do you begin to use logical thought process?
No
Risk of falls increases
The result is accurate patient dB
School age childen

20. Subjective data could include
Symptoms
8.4
To ID the problem
Initial assessment

21. Ageusia is
Initial assessment
No
The patient
Loss of taste

22. Which patient would be most likely to experience sensory overload?
School age childen
Focused
An 80 y/o patient that has emergency surgery
Pt's with oxygenation and perfusion problems

23. In Which part of the nursing process will you find delegation?
Communicate using hands and eyes.
Implementation
Irregular respirations (fast/slow) often seen at end of life
Pt's underlying feelings

24. What are the ABCDE's of pain management?
Hygeine - DOB - work hx
Ask - Believe - Choose - Deliver - Empower
Risk of falls increases
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy

25. When using restraints in a confused patient
Viral infection
Symptoms
Risk of falls increases
Knowing What to do/how to make a decision based upon available data.

26. What is responsible for transporting O2 in the blood
Initial assessment
No
Hearing loss
Hemoglobin

27. When performing an ongoing assessment for a patient with disturbed thinking the nurse should be sure to include
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
The result is accurate patient dB
Level of stress - risk for violence - anxiety level - patient unmet needs

28. Data gathered via instrumention (pulse ox) is considered
Objective
Non - opiod (ex: NSAID/acetominaphen)
Decreased sense of taste
Confusion Assessment Method

29. Keeping patient's belongings - shoes - suitcases and street clothes - etc. out of view are helpful for preventing: wandering?
The patient
Wandering
Assess over all health status and identify the problem
Trauma or illness

30. What is the difference between hallucination and delirium?
Preschool is cause and effect - school age begins to use logical thought process.
Decreased arterial perfusion
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances

31. Side effects of putting confused pts in restraints include
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Medical

32. At What age do you begin to put thoughts into words?
Toddler
A false - fixed belief that cannot be corrected through reasoning.
Secondary soureces (family - friends)
Surgically implanted device for deaf or hard or hearing - also called bionic ear.

33. What is pain?
Daily
Non - opiod (ex: NSAID/acetominaphen)
Trauma or illness
A personal experience that does whatever the person in pain says it does

34. The path of blood from the heart to the lungs is
The process of storing - learning - retrieving - and using info.
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Serves to expedite dx and tx of actual and potential health problems

35. Two indicators that are REQUIRED for classification via the CAM tool include
Non - opiod (ex: NSAID/acetominaphen)
Inattention and acute increase/decrease in cognitive function
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Vesicular (peripheral lung areas)

36. 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
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Double check equip and patient
No

37. Blood passes through the heart valves In what order?
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Pt's underlying feelings
Pain on inspiration and expiration; superficial squeaking or grating
Tricuspid - mitral and the aortic

38. Why are young children at greater risk for respiratory infection?
Focused
Interventions for which the nurse is accountable
Immature immune system - structures close together lends to easy spreading from on area to another.
Tricuspid - mitral and the aortic

39. What is cognition?
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
A false - fixed belief that cannot be corrected through reasoning.
The process of storing - learning - retrieving - and using info.

40. One way to test a person's cognitive ability and abstract thinking ability would be to
Have them do simple math problems
Objective
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
Secondary

41. What are the components of an assessment?
Fluid volume deficit related to poor intake
Trauma or illness
Secondary soureces (family - friends)
Data collection - data validation - data organization - data analysis - and data reporting/recording.

42. When noticing a patient with dementia has stopped eating - the RN's first response is?
Hemoglobin
To simulate eating motions with the hands
A personal experience that does whatever the person in pain says it does
Initial assessment

43. Sleep deprivation can effect
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Learning - memory and adaptation to stress
Loss of taste

44. An example of a secondary source is
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
# of packs per day x # of years smoked
Family - spouse - someone other than a healthcare worker - previous medical records.
School age childen

45. What scale is used to determine eating and feeding issues in adults with confusion
Disorganized thinking and altered LOC
Focused
EdFED- Q
Bacterial infection

46. Factors that may reduce the efficacy of pulse oximetry include
Have them do simple math problems
Defining a baseline of cognitive function - any changes or deviations from norm.
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Edema

47. What is a chochlear implant?
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
ID'ing status of exisiting problems and locating new issues
Family - spouse - someone other than a healthcare worker - previous medical records.

48. If patient reports pain of 3 on scale of 0-10 - What is the appropriate class of pain reliever?
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Non - opiod (ex: NSAID/acetominaphen)
Upper airways

49. What is the nursing process?
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Broncial (heard over trachea)
EdFED- Q
The result is accurate patient dB

50. What is a component of the cognitive part of critical thinking skills?
Fast and deep respirations seen in patient's with acidosis
Nursing
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

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Nursing Fundamentals 3

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