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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. Other factors that may indicate confusion using the CAM tool could be
Disorganized thinking and altered LOC
Pain
Have them do simple math problems
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response

2. Asking a patient what would you do if there is a fire in the wastebasket - is a way to assess their
To ID the problem
To simulate eating motions with the hands
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Abstract thinking

3. The basis for a plan of care comes for which stage of the nursing process?
Non - opiod (ex: NSAID/acetominaphen)
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Nursing dx
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response

4. Would a nursing dx be part of the primary or secondary dx?
Capillaries
Medical
Secondary
Vesicular (peripheral lung areas)

5. An example of a secondary source is
Inattention and acute increase/decrease in cognitive function
Family - spouse - someone other than a healthcare worker - previous medical records.
Snap - crackle - pops; velcro - bubble wrap
Level of stress - risk for violence - anxiety level - patient unmet needs

6. What is responsible for transporting O2 in the blood
Defining a baseline of cognitive function - any changes or deviations from norm.
Learning - memory and adaptation to stress
Fluid volume deficit related to poor intake
Hemoglobin

7. Why are young children at greater risk for respiratory infection?
Immature immune system - structures close together lends to easy spreading from on area to another.
Hygeine - DOB - work hx
Non - opiod (ex: NSAID/acetominaphen)
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy

8. Sleep deprivation can effect
Sensory motor
Learning - memory and adaptation to stress
Upper airways
Trauma or illness

9. Ongoing assessments are useful in

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10. Data from the last 24/48 hours that included patterns would be a part of
Trend assessment (shift report)
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Preschool is cause and effect - school age begins to use logical thought process.
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy

11. When performing an ongoing assessment for a patient with disturbed thinking the nurse should be sure to include
Abstract thinking
The medication will not affect the patient's breathing.
Level of stress - risk for violence - anxiety level - patient unmet needs
Tricuspid - mitral and the aortic

12. Acceptable sources of assessment data when evaluating a confused patient would be
Decreased arterial perfusion
Secondary soureces (family - friends)
# of packs per day x # of years smoked
Fast and deep respirations seen in patient's with acidosis

13. The order of air flow into the lungs is
Ongoing assessment
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
Stroke volume x's heart rate
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.

14. Nursing interventions should be based on who's theory?
Objective
Edema
Maslow
Symptoms

15. Inspiration sounds are heard longer than expiration sounds In What area?
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Having to use more than one pillow when sleeping
Vesicular (peripheral lung areas)
Double check equip and patient

16. Side effects of putting confused pts in restraints include
Pain
Decision assessment
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Upper airways

17. Intermittent claudication is caused by?
Viral infection
Focused
Decreased arterial perfusion
Ongoing assessment

18. At What age do you begin to use logical thought process?
School age childen
ID'ing status of exisiting problems and locating new issues
Risk of falls increases
Disorganized thinking and altered LOC

19. What is the correct approach when dealing with older adults?
Interventions for which the nurse is accountable
Confusion Assessment Method
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
No

20. If patient reports pain of 3 on scale of 0-10 - What is the appropriate class of pain reliever?
Objective
Communicate using hands and eyes.
Non - opiod (ex: NSAID/acetominaphen)
Stroke volume x's heart rate

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

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22. A patient that is easily fatigued may have a HgB lab value of?
Implementation
Defining a baseline of cognitive function - any changes or deviations from norm.
Pain on inspiration and expiration; superficial squeaking or grating
8.4

23. What scale is used to determine eating and feeding issues in adults with confusion
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Broncial (heard over trachea)
Secondary
EdFED- Q

24. Data validation assures
The result is accurate patient dB
8.4
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Medical

25. Keeping patient's belongings - shoes - suitcases and street clothes - etc. out of view are helpful for preventing: wandering?
Wandering
Confusion Assessment Method
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Focused

26. 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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27. Two indicators that are REQUIRED for classification via the CAM tool include
To ID the problem
Inattention and acute increase/decrease in cognitive function
# of packs per day x # of years smoked
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.

28. The path of blood from the heart to the lungs is
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
The process of storing - learning - retrieving - and using info.
Having to use more than one pillow when sleeping
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins

29. Another term for a focused assessment is
Assess over all health status and identify the problem
Ongoing assessment
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)

30. The site where gas exchange occurs is
Preschool is cause and effect - school age begins to use logical thought process.
Knowing What to do/how to make a decision based upon available data.
Capillaries
Level of stress - risk for violence - anxiety level - patient unmet needs

31. The purpose of an intitial assement serves to?
Immature immune system - structures close together lends to easy spreading from on area to another.
Assess over all health status and identify the problem
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Maslow

32. What are the steps of the nursing process?
Edema
ID'ing status of exisiting problems and locating new issues
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Sensory motor

33. A nursing dx is best described as
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Double check equip and patient

34. What is a definition of a delusion?
Objective
Disorganized thinking and altered LOC
The process of storing - learning - retrieving - and using info.
A false - fixed belief that cannot be corrected through reasoning.

35. When performing an interview with a patient with vision loss - select the correct questions for obtaining an accurate vision history
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Have them do simple math problems
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
Defining a baseline of cognitive function - any changes or deviations from norm.

36. Expiration sounds are heard longer than inspiration In What area?
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
EdFED- Q
Broncial (heard over trachea)

37. What is a chochlear implant?
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
Nursing dx
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Nurse

38. All body system data is not necessary which type of assessment
Sensory motor
Loss of taste
Focused
Pain

39. Blood passes through the heart valves In what order?
Toddler
Tricuspid - mitral and the aortic
To simulate eating motions with the hands
To ID the problem

40. What is the purpose of the nursing process?
Defining a baseline of cognitive function - any changes or deviations from norm.
Serves to expedite dx and tx of actual and potential health problems
Hearing loss
To simulate eating motions with the hands

41. Hypogeusis is
Having to use more than one pillow when sleeping
Capillaries
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Decreased sense of taste

42. Ageusia is
Fast and deep respirations seen in patient's with acidosis
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
Loss of taste
Risk of falls increases

43. What are the components of an assessment?
An 80 y/o patient that has emergency surgery
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Loss of taste
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response

44. An infant is in which Paiget stage?
Loss of taste
Bacterial infection
Sensory motor
Medical

45. What is the cognitive difference between a preschooler and schoolage child?
Preschool is cause and effect - school age begins to use logical thought process.
The result is accurate patient dB
Initial assessment
No

46. Diabetes is a _________ dx
Sensory motor
Medical
Pt's with oxygenation and perfusion problems
Hygeine - DOB - work hx

47. 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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48. At What age do you begin to use decision making?
Adolescence
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
Stroke volume x's heart rate
Hearing loss

49. When using restraints in a confused patient
Capillaries
Trauma or illness
Risk of falls increases
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)

50. Data gathered via instrumention (pulse ox) is considered
Bacterial infection
Objective
Capillaries
Preschool is cause and effect - school age begins to use logical thought process.