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Nursing Fundamentals 3

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Answer 50 questions in 15 minutes.
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Match each statement with the correct term.
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1. What are Piaget's stages of cognitive development
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
No
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.

2. When a patient has increased lymphocytes - this may indicate what?
The result is accurate patient dB
To simulate eating motions with the hands
To ID the problem
Viral infection

3. A nursing dx is best described as
Toddler
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Disorganized thinking and altered LOC

4. If patient reports pain of 3 on scale of 0-10 - What is the appropriate class of pain reliever?
Interventions for which the nurse is accountable
To ID the problem
Non - opiod (ex: NSAID/acetominaphen)
Focused

5. Keeping patient's belongings - shoes - suitcases and street clothes - etc. out of view are helpful for preventing: wandering?
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
8.4
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
Wandering

6. Subjective data could include
Symptoms
Defining a baseline of cognitive function - any changes or deviations from norm.
Ask - Believe - Choose - Deliver - Empower
The process of storing - learning - retrieving - and using info.

7. Describe the purpose of a mental status exam
Defining a baseline of cognitive function - any changes or deviations from norm.
Immature immune system - structures close together lends to easy spreading from on area to another.
Objective
Confusion Assessment Method

8. What is the cognitive difference between a preschooler and schoolage child?
Have them do simple math problems
Level of stress - risk for violence - anxiety level - patient unmet needs
Preschool is cause and effect - school age begins to use logical thought process.
Ongoing assessment

9. What is a component of the cognitive part of critical thinking skills?
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Wandering
Knowing What to do/how to make a decision based upon available data.

10. Examples of personal information
Risk of falls increases
Nursing dx
Hygeine - DOB - work hx
Family - spouse - someone other than a healthcare worker - previous medical records.

11. When a patient has increased neutrophils - this may indicate what?
Sensory motor
Bacterial infection
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation

12. Kussamaul respirations describe

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13. What is cognition?
The process of storing - learning - retrieving - and using info.
Stroke volume x's heart rate
ID'ing status of exisiting problems and locating new issues
Knowing What to do/how to make a decision based upon available data.

14. Once a medical dx has been made - who is accountable for the reporting s/s of complications?
Abstract thinking
Nurse
A false - fixed belief that cannot be corrected through reasoning.
Viral infection

15. One way to test a person's cognitive ability and abstract thinking ability would be to
Immature immune system - structures close together lends to easy spreading from on area to another.
Trend assessment (shift report)
Have them do simple math problems
Capillaries

16. In Which part of the nursing process will you find delegation?
Secondary
Fast and deep respirations seen in patient's with acidosis
Initial assessment
Implementation

17. Where can wheezes best be heard?
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Family - spouse - someone other than a healthcare worker - previous medical records.
Upper airways

18. What are the components of an assessment?
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
To simulate eating motions with the hands
Data collection - data validation - data organization - data analysis - and data reporting/recording.
ID'ing status of exisiting problems and locating new issues

19. When performing an ongoing assessment for a patient with disturbed thinking the nurse should be sure to include
Level of stress - risk for violence - anxiety level - patient unmet needs
Preschool is cause and effect - school age begins to use logical thought process.
ID'ing status of exisiting problems and locating new issues
Decision assessment

20. The purpose of an initial assessment is
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
The result is accurate patient dB
Viral infection
To ID the problem

21. Nursing dx provides basis of
Viral infection
Interventions for which the nurse is accountable
Trauma or illness
Serves to expedite dx and tx of actual and potential health problems

22. What is the purpose of the nursing process?
Serves to expedite dx and tx of actual and potential health problems
Inattention and acute increase/decrease in cognitive function
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Non - opiod (ex: NSAID/acetominaphen)

23. 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.
Implementation
The process of storing - learning - retrieving - and using info.
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)

24. Other factors that may indicate confusion using the CAM tool could be
A personal experience that does whatever the person in pain says it does
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Disorganized thinking and altered LOC

25. When performing an interview with a patient with vision loss - select the correct questions for obtaining an accurate vision history
ID'ing status of exisiting problems and locating new issues
Preschool is cause and effect - school age begins to use logical thought process.
Immature immune system - structures close together lends to easy spreading from on area to another.
Eye hygeine - accomodating factors - what was the level of decline - how long has it been

26. Diabetes is a _________ dx
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Medical
Pain on inspiration and expiration; superficial squeaking or grating
The medication will not affect the patient's breathing.

27. Data gathered via instrumention (pulse ox) is considered
Medical
Toddler
Pain
Objective

28. What is the difference between a nursing dx and a med dx?
Family - spouse - someone other than a healthcare worker - previous medical records.
Confusion Assessment Method
Non - opiod (ex: NSAID/acetominaphen)
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital

29. The path of blood from the lungs to the heart is
Symptoms
Stroke volume x's heart rate
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response

30. An example of a secondary source is
Assess over all health status and identify the problem
Family - spouse - someone other than a healthcare worker - previous medical records.
Defining a baseline of cognitive function - any changes or deviations from norm.
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts

31. The fifth vital sign is
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
An 80 y/o patient that has emergency surgery
Learning - memory and adaptation to stress
Pain

32. What would cause changes in congitive development later in life (middle adulthood)?
Upper airways
Broncial (heard over trachea)
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Trauma or illness

33. Blood passes through the heart valves In what order?
Hygeine - DOB - work hx
Tricuspid - mitral and the aortic
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Hemoglobin

34. Types of hearing loss include
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.
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
Ask - Believe - Choose - Deliver - Empower

35. Ongoing assessments are useful in

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36. Factors that may reduce the efficacy of pulse oximetry include
An 80 y/o patient that has emergency surgery
Hearing loss
8.4
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -

37. What are the ABCDE's of pain management?
Stroke volume x's heart rate
Pt's underlying feelings
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Ask - Believe - Choose - Deliver - Empower

38. Expiration sounds are heard longer than inspiration In What area?
Focused
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
A personal experience that does whatever the person in pain says it does
Broncial (heard over trachea)

39. Are changes in vital signs a reliable indicator of chronic pain?
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Assess over all health status and identify the problem
No

40. The path of blood from the heart to the lungs is
Tricuspid - mitral and the aortic
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Level of stress - risk for violence - anxiety level - patient unmet needs
The patient

41. What are the steps of the nursing process?
Wandering
Tricuspid - mitral and the aortic
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
EdFED- Q

42. The assessment that includes the patient's overhall health status
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Focused
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
Initial assessment

43. Ageusia is
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Broncial (heard over trachea)
Loss of taste
Fast and deep respirations seen in patient's with acidosis

44. The basis for a plan of care comes for which stage of the nursing process?
A personal experience that does whatever the person in pain says it does
Stroke volume x's heart rate
To simulate eating motions with the hands
Nursing dx

45. What are Cheyne Stokes?
Fluid volume deficit related to poor intake
Pt's with oxygenation and perfusion problems
Irregular respirations (fast/slow) often seen at end of life
Pain

46. Data that is recorded for an immediate need (code blue or fall) would be included in
Disorganized thinking and altered LOC
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Decision assessment

47. When speaking with a patient with moderate hearing loss the RN should
Symptoms
Medical
An 80 y/o patient that has emergency surgery
Communicate using hands and eyes.

48. What is the difference between hallucination and delirium?
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Broncial (heard over trachea)
Assess over all health status and identify the problem
Loss of taste

49. Which patient would be most likely to experience sensory overload?
Symptoms
The medication will not affect the patient's breathing.
An 80 y/o patient that has emergency surgery
A false - fixed belief that cannot be corrected through reasoning.

50. An example of a primary source is
Fluid volume deficit related to poor intake
The patient
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -

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Nursing Fundamentals 3

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