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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. The fifth vital sign is
Pain
Have them do simple math problems
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
ID'ing status of exisiting problems and locating new issues

2. When speaking with a patient with moderate hearing loss the RN should
Preschool is cause and effect - school age begins to use logical thought process.
Pain
Disorganized thinking and altered LOC
Communicate using hands and eyes.

3. At patient that state their shoes are tighter at the end of the day may be experiencing
Pain on inspiration and expiration; superficial squeaking or grating
Edema
Pt's with oxygenation and perfusion problems
Trend assessment (shift report)

4. What is the cognitive difference between a preschooler and schoolage child?
Preschool is cause and effect - school age begins to use logical thought process.
Decision assessment
Adolescence
Learning - memory and adaptation to stress

5. What is the formula for determining pack years?
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
# of packs per day x # of years smoked
Trauma or illness

6. QUESTT is a tool for What type of an assessment?
The result is accurate patient dB
ID'ing status of exisiting problems and locating new issues
Pain
Paradoxical reaction

7. Are changes in vital signs a reliable indicator of chronic pain?
Nurse
# of packs per day x # of years smoked
Pt's underlying feelings
No

8. Ageusia is
Edema
Loss of taste
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Nursing

9. At What age do you begin to use logical thought process?
Nurse
School age childen
Abstract thinking
Fluid volume deficit related to poor intake

10. Intermittent claudication is caused by?
Double check equip and patient
# of packs per day x # of years smoked
Decreased arterial perfusion
Knowing What to do/how to make a decision based upon available data.

11. What does CAM stand for
Confusion Assessment Method
Fluid volume deficit related to poor intake
Learning - memory and adaptation to stress
Decreased arterial perfusion

12. An example of a nursing dx would be
Interventions for which the nurse is accountable
Fluid volume deficit related to poor intake
Serves to expedite dx and tx of actual and potential health problems
Knowing What to do/how to make a decision based upon available data.

13. What are the components of a mental status exam that are not part of a regular assessment?
Focused
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
Decision assessment
8.4

14. Fluid volume deficit is a __________ dx
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Upper airways
Nursing
Edema

15. Nursing dx provides basis of
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
Interventions for which the nurse is accountable
No

16. The path of blood from the heart to the lungs is
Trauma or illness
Initial assessment
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Bacterial infection

17. Data that is recorded for an immediate need (code blue or fall) would be included in
Defining a baseline of cognitive function - any changes or deviations from norm.
Decision assessment
Communicate using hands and eyes.
Decreased sense of taste

18. Ongoing assessments are useful in

19. The order of air flow into the lungs is
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
Learning - memory and adaptation to stress
Double check equip and patient
The result is accurate patient dB

20. What is a definition of a delusion?
Confusion Assessment Method
Objective
Ask - Believe - Choose - Deliver - Empower
A false - fixed belief that cannot be corrected through reasoning.

21. What scale is used to determine eating and feeding issues in adults with confusion
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Trauma or illness
Broncial (heard over trachea)
EdFED- Q

22. What is cognition?
Pain on inspiration and expiration; superficial squeaking or grating
To ID the problem
The process of storing - learning - retrieving - and using info.
A false - fixed belief that cannot be corrected through reasoning.

23. What are the ABCDE's of pain management?
Ask - Believe - Choose - Deliver - Empower
Knowing What to do/how to make a decision based upon available data.
Nursing
Hygeine - DOB - work hx

24. Name the 5 'W's' of assessing a change in LOC
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
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)

25. When performing an interview with a patient with vision loss - select the correct questions for obtaining an accurate vision history
Paradoxical reaction
Hemoglobin
Upper airways
Eye hygeine - accomodating factors - what was the level of decline - how long has it been

26. Would a nursing dx be part of the primary or secondary dx?
Secondary
To simulate eating motions with the hands
Toddler
Surgically implanted device for deaf or hard or hearing - also called bionic ear.

27. A patient that is easily fatigued may have a HgB lab value of?
Having to use more than one pillow when sleeping
Preschool is cause and effect - school age begins to use logical thought process.
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
8.4

28. What is intermittent claudication?
Pain in legs assoc w walking
To ID the problem
Loss of taste
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)

29. Examples of personal information
To simulate eating motions with the hands
Viral infection
Hygeine - DOB - work hx
Broncial (heard over trachea)

30. A patient failing to answer questions or displaying a reluctance to participate in group or family activities may be experiencing
ID'ing status of exisiting problems and locating new issues
Pain in legs assoc w walking
Hearing loss
To simulate eating motions with the hands

31. Which patient would be most likely to experience sensory overload?
Adolescence
Disorganized thinking and altered LOC
An 80 y/o patient that has emergency surgery
Trend assessment (shift report)

32. Keeping patient's belongings - shoes - suitcases and street clothes - etc. out of view are helpful for preventing: wandering?
Abstract thinking
Ongoing assessment
ID'ing status of exisiting problems and locating new issues
Wandering

33. The basis for a plan of care comes for which stage of the nursing process?
Trauma or illness
Nursing dx
Pain in legs assoc w walking
EdFED- Q

34. Types of hearing loss include
An 80 y/o patient that has emergency surgery
Upper airways
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
Adolescence

35. 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 -
Having to use more than one pillow when sleeping
Snap - crackle - pops; velcro - bubble wrap
# of packs per day x # of years smoked

36. The purpose of an intitial assement serves to?
Confusion Assessment Method
Assess over all health status and identify the problem
8.4
Paradoxical reaction

37. An example of a primary source is
The patient
Learning - memory and adaptation to stress
To simulate eating motions with the hands
Implementation

38. Side effects of putting confused pts in restraints 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)
Pain on inspiration and expiration; superficial squeaking or grating
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Knowing What to do/how to make a decision based upon available data.

39. One way to test a person's cognitive ability and abstract thinking ability would be to
Trend assessment (shift report)
Objective
The process of storing - learning - retrieving - and using info.
Have them do simple math problems

40. Data gathered via instrumention (pulse ox) is considered
The patient
EdFED- Q
Objective
Abstract thinking

41. Inspiration sounds are heard longer than expiration sounds In What area?
Vesicular (peripheral lung areas)
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Pt's underlying feelings
Trauma or illness

42. Expiration sounds are heard longer than inspiration In What area?
Broncial (heard over trachea)
Have them do simple math problems
Hygeine - DOB - work hx
Snap - crackle - pops; velcro - bubble wrap

43. What do rales sound like?
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Toddler
Snap - crackle - pops; velcro - bubble wrap

44. The path of blood from the lungs to the heart is
Tricuspid - mitral and the aortic
Disorganized thinking and altered LOC
Pain
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve

45. Why are young children at greater risk for respiratory infection?
No
To simulate eating motions with the hands
Immature immune system - structures close together lends to easy spreading from on area to another.
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins

46. What is a chochlear implant?
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Decision assessment
Non - opiod (ex: NSAID/acetominaphen)
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.

47. What is pain?
No
Pain
A personal experience that does whatever the person in pain says it does
Implementation

48. What would cause changes in congitive development later in life (middle adulthood)?
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Trauma or illness
Maslow

49. What are the steps of the nursing process?
Immature immune system - structures close together lends to easy spreading from on area to another.
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
Objective

50. What factors may indicate plural rub?
Pain on inspiration and expiration; superficial squeaking or grating
Adolescence
Abstract thinking
Risk of falls increases