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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. What is the correct approach when dealing with older adults?
Interventions for which the nurse is accountable
Nursing
Decision assessment
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response

2. What is cognition?
The process of storing - learning - retrieving - and using info.
ID'ing status of exisiting problems and locating new issues
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins

3. What are Piaget's stages of cognitive development
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
Having to use more than one pillow when sleeping
Risk of falls increases
An 80 y/o patient that has emergency surgery

4. Factors that may reduce the efficacy of pulse oximetry include
Snap - crackle - pops; velcro - bubble wrap
Double check equip and patient
Irregular respirations (fast/slow) often seen at end of life
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -

5. The site where gas exchange occurs is
A personal experience that does whatever the person in pain says it does
Symptoms
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
Capillaries

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

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

8. An example of a secondary source is
Family - spouse - someone other than a healthcare worker - previous medical records.
Focused
Maslow
Objective

9. All body system data is not necessary which type of assessment
Focused
Sensory motor
# of packs per day x # of years smoked
Initial assessment

10. 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)
Hearing loss
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Irregular respirations (fast/slow) often seen at end of life

11. Sleep deprivation can effect
Communicate using hands and eyes.
Learning - memory and adaptation to stress
Pain in legs assoc w walking
Vesicular (peripheral lung areas)

12. When using restraints in a confused patient
Secondary soureces (family - friends)
EdFED- Q
An 80 y/o patient that has emergency surgery
Risk of falls increases

13. At What age do you begin to use decision making?
Vesicular (peripheral lung areas)
Bacterial infection
Adolescence
Tricuspid - mitral and the aortic

14. The purpose of an intitial assement serves to?
Loss of taste
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Assess over all health status and identify the problem

15. When speaking with a patient with moderate hearing loss the RN should
Adolescence
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Symptoms
Communicate using hands and eyes.

16. Keeping patient's belongings - shoes - suitcases and street clothes - etc. out of view are helpful for preventing: wandering?
The patient
Wandering
Interventions for which the nurse is accountable
Pt's with oxygenation and perfusion problems

17. When a patient has increased lymphocytes - this may indicate what?
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
The medication will not affect the patient's breathing.
Viral infection
Learning - memory and adaptation to stress

18. The fifth vital sign is
School age childen
Level of stress - risk for violence - anxiety level - patient unmet needs
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Pain

19. The order of air flow into the lungs is
To ID the problem
# of packs per day x # of years smoked
Pain
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli

20. What would cause changes in congitive development later in life (middle adulthood)?
Pain
Nursing dx
Communicate using hands and eyes.
Trauma or illness

21. Data that is recorded for an immediate need (code blue or fall) would be included in
Disorganized thinking and altered LOC
Daily
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Decision assessment

22. An example of a nursing dx would be
Fluid volume deficit related to poor intake
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
To simulate eating motions with the hands

23. What is the difference between a nursing dx and a med dx?
Immature immune system - structures close together lends to easy spreading from on area to another.
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Fluid volume deficit related to poor intake

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

25. Name the 5 'W's' of assessing a change in LOC
Nurse
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
A personal experience that does whatever the person in pain says it does

26. Once a medical dx has been made - who is accountable for the reporting s/s of complications?
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
Nurse
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve

27. Examples of personal information
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Family - spouse - someone other than a healthcare worker - previous medical records.
Interventions for which the nurse is accountable
Hygeine - DOB - work hx

28. What is the formula for determining pack years?
Nursing dx
Objective
Having to use more than one pillow when sleeping
# of packs per day x # of years smoked

29. QUESTT is a tool for What type of an assessment?
Pain
Secondary soureces (family - friends)
Symptoms
Having to use more than one pillow when sleeping

30. Ageusia is
Hearing loss
Non - opiod (ex: NSAID/acetominaphen)
Loss of taste
Inattention and acute increase/decrease in cognitive function

31. Would a nursing dx be part of the primary or secondary dx?
The result is accurate patient dB
Pain in legs assoc w walking
Hemoglobin
Secondary

32. Other factors that may indicate confusion using the CAM tool could be
Family - spouse - someone other than a healthcare worker - previous medical records.
Pain
Pain in legs assoc w walking
Disorganized thinking and altered LOC

33. Where can wheezes best be heard?
Upper airways
Edema
Loss of taste
Pain

34. At What age do you begin to put thoughts into words?
Focused
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Initial assessment
Toddler

35. Why are young children at greater risk for respiratory infection?
Inattention and acute increase/decrease in cognitive function
To simulate eating motions with the hands
Immature immune system - structures close together lends to easy spreading from on area to another.
Snap - crackle - pops; velcro - bubble wrap

36. What do rales sound like?
Communicate using hands and eyes.
Hearing loss
Snap - crackle - pops; velcro - bubble wrap
Fluid volume deficit related to poor intake

37. A patient failing to answer questions or displaying a reluctance to participate in group or family activities may be experiencing
Hearing loss
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Edema
Learning - memory and adaptation to stress

38. Another term for a focused assessment is
Paradoxical reaction
Trauma or illness
Serves to expedite dx and tx of actual and potential health problems
Ongoing assessment

39. What are the components of a mental status exam that are not part of a regular assessment?
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
EdFED- Q
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances

40. When a patient has increased neutrophils - this may indicate what?
Bacterial infection
Pain in legs assoc w walking
Edema
Knowing What to do/how to make a decision based upon available data.

41. Hypogeusis is
To simulate eating motions with the hands
Irregular respirations (fast/slow) often seen at end of life
Decreased sense of taste
# of packs per day x # of years smoked

42. Kussamaul respirations describe

43. The assessment that includes the patient's overhall health status
Abstract thinking
Secondary soureces (family - friends)
Communicate using hands and eyes.
Initial assessment

44. What are Cheyne Stokes?
Trend assessment (shift report)
Irregular respirations (fast/slow) often seen at end of life
The patient
Toddler

45. Blood passes through the heart valves In what order?
Decreased arterial perfusion
Capillaries
Tricuspid - mitral and the aortic
Paradoxical reaction

46. At What age do you begin to use logical thought process?
Focused
Pain
School age childen
Hearing loss

47. What is the formula for cardiac output?

48. The path of blood from the heart to the lungs is
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Adolescence
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins

49. What does CAM stand for
Abstract thinking
Medical
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
Confusion Assessment Method

50. Data from the last 24/48 hours that included patterns would be a part of
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
The result is accurate patient dB
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Trend assessment (shift report)