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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. Nursing dx provides basis of
Focused
Interventions for which the nurse is accountable
Pain
Pain in legs assoc w walking

2. Examples of personal information
A personal experience that does whatever the person in pain says it does
Disorganized thinking and altered LOC
Hygeine - DOB - work hx
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)

3. The purpose of an intitial assement serves to?
Interventions for which the nurse is accountable
Objective
An 80 y/o patient that has emergency surgery
Assess over all health status and identify the problem

4. Side effects of putting confused pts in restraints include
Upper airways
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Capillaries
Interventions for which the nurse is accountable

5. A patient failing to answer questions or displaying a reluctance to participate in group or family activities may be experiencing
Interventions for which the nurse is accountable
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
Pt's underlying feelings
Hearing loss

6. Where can wheezes best be heard?
Focused
Upper airways
Objective
Defining a baseline of cognitive function - any changes or deviations from norm.

7. An example of a secondary source is
Risk of falls increases
Wandering
Medical
Family - spouse - someone other than a healthcare worker - previous medical records.

8. A patient that is easily fatigued may have a HgB lab value of?
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
EdFED- Q
8.4
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital

9. Once a medical dx has been made - who is accountable for the reporting s/s of complications?
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
ID'ing status of exisiting problems and locating new issues
Nurse
Decision assessment

10. An infant is in which Paiget stage?
Sensory motor
Maslow
Ask - Believe - Choose - Deliver - Empower
School age childen

11. 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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12. What are the components of a mental status exam that are not part of a regular assessment?
Level of stress - risk for violence - anxiety level - patient unmet needs
Double check equip and patient
Nursing
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances

13. What is the cognitive difference between a preschooler and schoolage child?
Family - spouse - someone other than a healthcare worker - previous medical records.
Have them do simple math problems
Preschool is cause and effect - school age begins to use logical thought process.
Secondary

14. Diabetes is a _________ dx
Bacterial infection
Medical
A false - fixed belief that cannot be corrected through reasoning.
Toddler

15. What is a chochlear implant?
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Stroke volume x's heart rate
Focused

16. At What age do you begin to use logical thought process?
Decreased arterial perfusion
School age childen
Secondary
Abstract thinking

17. What is the formula for determining pack years?
Initial assessment
Non - opiod (ex: NSAID/acetominaphen)
# of packs per day x # of years smoked
Immature immune system - structures close together lends to easy spreading from on area to another.

18. Are changes in vital signs a reliable indicator of chronic pain?
Toddler
No
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
The medication will not affect the patient's breathing.

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

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20. What is responsible for transporting O2 in the blood
A false - fixed belief that cannot be corrected through reasoning.
Symptoms
Hemoglobin
Loss of taste

21. What does CAM stand for
Confusion Assessment Method
ID'ing status of exisiting problems and locating new issues
Double check equip and patient
Serves to expedite dx and tx of actual and potential health problems

22. The path of blood from the lungs to the heart is
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Nurse
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Bacterial infection

23. Intermittent claudication is caused by?
Decreased arterial perfusion
Stroke volume x's heart rate
Family - spouse - someone other than a healthcare worker - previous medical records.
Edema

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

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25. What factors may indicate plural rub?
Pt's underlying feelings
A personal experience that does whatever the person in pain says it does
Having to use more than one pillow when sleeping
Pain on inspiration and expiration; superficial squeaking or grating

26. The fifth vital sign is
Nursing dx
Pain
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Focused

27. Fluid volume deficit is a __________ dx
Communicate using hands and eyes.
Learning - memory and adaptation to stress
Nursing
Stroke volume x's heart rate

28. An example of a primary source is
Broncial (heard over trachea)
Bacterial infection
The patient
EdFED- Q

29. When noticing a patient with dementia has stopped eating - the RN's first response is?
To simulate eating motions with the hands
The medication will not affect the patient's breathing.
Double check equip and patient
Pt's with oxygenation and perfusion problems

30. What do rhonchi sound like?
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
An 80 y/o patient that has emergency surgery
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Risk of falls increases

31. Other factors that may indicate confusion using the CAM tool could be
Medical
Symptoms
Disorganized thinking and altered LOC
A false - fixed belief that cannot be corrected through reasoning.

32. The basis for a plan of care comes for which stage of the nursing process?
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
The result is accurate patient dB
Nursing dx
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.

33. Describe the purpose of a mental status exam
Have them do simple math problems
Defining a baseline of cognitive function - any changes or deviations from norm.
To simulate eating motions with the hands
Surgically implanted device for deaf or hard or hearing - also called bionic ear.

34. What is the formula for cardiac output?

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35. Nursing interventions should be based on who's theory?
Maslow
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Nursing dx

36. When a patient has increased lymphocytes - this may indicate what?
# of packs per day x # of years smoked
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Learning - memory and adaptation to stress
Viral infection

37. The purpose of an initial assessment is
To ID the problem
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Tricuspid - mitral and the aortic
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins

38. Two indicators that are REQUIRED for classification via the CAM tool include
Hemoglobin
Broncial (heard over trachea)
Interventions for which the nurse is accountable
Inattention and acute increase/decrease in cognitive function

39. One way to test a person's cognitive ability and abstract thinking ability would be to
Have them do simple math problems
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
Fluid volume deficit related to poor intake

40. What is a definition of a delusion?
8.4
Risk of falls increases
A false - fixed belief that cannot be corrected through reasoning.
Having to use more than one pillow when sleeping

41. Expiration sounds are heard longer than inspiration In What area?
Symptoms
Broncial (heard over trachea)
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
Non - opiod (ex: NSAID/acetominaphen)

42. A nursing dx is best described as
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.
A false - fixed belief that cannot be corrected through reasoning.
8.4

43. When a patient has increased neutrophils - this may indicate what?
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
Bacterial infection
Ask - Believe - Choose - Deliver - Empower
Capillaries

44. Inspiration sounds are heard longer than expiration sounds In What area?
The process of storing - learning - retrieving - and using info.
Nursing dx
Double check equip and patient
Vesicular (peripheral lung areas)

45. Data from the last 24/48 hours that included patterns would be a part of
Double check equip and patient
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
EdFED- Q
Trend assessment (shift report)

46. What is a component of the cognitive part of critical thinking skills?
Defining a baseline of cognitive function - any changes or deviations from norm.
Knowing What to do/how to make a decision based upon available data.
Pt's underlying feelings
Daily

47. Data that is recorded for an immediate need (code blue or fall) would be included in
School age childen
Have them do simple math problems
Decision assessment
The process of storing - learning - retrieving - and using info.

48. Keeping patient's belongings - shoes - suitcases and street clothes - etc. out of view are helpful for preventing: wandering?
Wandering
Decreased arterial perfusion
Broncial (heard over trachea)
Daily

49. What scale is used to determine eating and feeding issues in adults with confusion
ID'ing status of exisiting problems and locating new issues
EdFED- Q
Interventions for which the nurse is accountable
Snap - crackle - pops; velcro - bubble wrap

50. What are the steps of the nursing process?
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Irregular respirations (fast/slow) often seen at end of life
Inattention and acute increase/decrease in cognitive function
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)