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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. Data gathered via instrumention (pulse ox) is considered
Medical
Objective
Hygeine - DOB - work hx
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.

2. What is the purpose of the nursing process?
Serves to expedite dx and tx of actual and potential health problems
Fast and deep respirations seen in patient's with acidosis
Ask - Believe - Choose - Deliver - Empower
Interventions for which the nurse is accountable

3. At What age do you begin to use decision making?
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Decreased arterial perfusion
Trauma or illness
Adolescence

4. The purpose of an initial assessment is
8.4
To ID the problem
Implementation
A personal experience that does whatever the person in pain says it does

5. Ageusia is
Loss of taste
Hygeine - DOB - work hx
Defining a baseline of cognitive function - any changes or deviations from norm.
To simulate eating motions with the hands

6. When performing an ongoing assessment for a patient with disturbed thinking the nurse should be sure to include
Decreased sense of taste
Inattention and acute increase/decrease in cognitive function
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Level of stress - risk for violence - anxiety level - patient unmet needs

7. What is the cognitive difference between a preschooler and schoolage child?
The patient
Disorganized thinking and altered LOC
Preschool is cause and effect - school age begins to use logical thought process.
The process of storing - learning - retrieving - and using info.

8. Which patient would be most likely to experience sensory overload?
Defining a baseline of cognitive function - any changes or deviations from norm.
Nurse
Secondary
An 80 y/o patient that has emergency surgery

9. Factors that may reduce the efficacy of pulse oximetry include
Sensory motor
Fast and deep respirations seen in patient's with acidosis
Pt's underlying feelings
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -

10. What is pain?
A personal experience that does whatever the person in pain says it does
Decision assessment
The patient
A false - fixed belief that cannot be corrected through reasoning.

11. Another term for a focused assessment is
Learning - memory and adaptation to stress
Ongoing assessment
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
No

12. Data from the last 24/48 hours that included patterns would be a part of
Toddler
Secondary soureces (family - friends)
Trend assessment (shift report)
Hearing loss

13. An example of a secondary source is
Secondary soureces (family - friends)
Symptoms
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Family - spouse - someone other than a healthcare worker - previous medical records.

14. The path of blood from the lungs to the heart is
Ask - Believe - Choose - Deliver - Empower
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
School age childen
Upper airways

15. Examples of personal information
Hygeine - DOB - work hx
Knowing What to do/how to make a decision based upon available data.
Decreased arterial perfusion
The process of storing - learning - retrieving - and using info.

16. A patient that is easily fatigued may have a HgB lab value of?
Fast and deep respirations seen in patient's with acidosis
8.4
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances

17. Intermittent claudication is caused by?
Irregular respirations (fast/slow) often seen at end of life
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
Decreased arterial perfusion
Wandering

18. All body system data is not necessary which type of assessment
Inattention and acute increase/decrease in cognitive function
Focused
Nurse
The patient

19. At What age do you begin to use logical thought process?
Trend assessment (shift report)
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
School age childen
ID'ing status of exisiting problems and locating new issues

20. Ongoing assessments are useful in

21. An ongoing assessment is performed
Having to use more than one pillow when sleeping
Adolescence
Nurse
Daily

22. What is the difference between hallucination and delirium?
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Risk of falls increases
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.

23. Where can you hear bronchovesicular breath sounds?
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Paradoxical reaction
Nurse
Assess over all health status and identify the problem

24. A potential adverse rx of chemically restraining a confused patient would be
Paradoxical reaction
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
Trend assessment (shift report)
Decreased arterial perfusion

25. When speaking with a patient with moderate hearing loss the RN should
Communicate using hands and eyes.
Abstract thinking
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Toddler

26. QUESTT is a tool for What type of an assessment?
Capillaries
A personal experience that does whatever the person in pain says it does
Pain
# of packs per day x # of years smoked

27. Blood passes through the heart valves In what order?
Communicate using hands and eyes.
Decreased arterial perfusion
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Tricuspid - mitral and the aortic

28. What is intermittent claudication?
An 80 y/o patient that has emergency surgery
Risk of falls increases
Pain in legs assoc w walking
Preschool is cause and effect - school age begins to use logical thought process.

29. Types of hearing loss include
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
The result is accurate patient dB
Inattention and acute increase/decrease in cognitive function

30. Diabetes is a _________ dx
Medical
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Implementation
8.4

31. The assessment that includes the patient's overhall health status
Nursing
Level of stress - risk for violence - anxiety level - patient unmet needs
EdFED- Q
Initial assessment

32. What is the formula for cardiac output?

33. Fluid volume deficit is a __________ dx
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Nursing
The process of storing - learning - retrieving - and using info.
School age childen

34. Data that is recorded for an immediate need (code blue or fall) would be included in
Learning - memory and adaptation to stress
Decision assessment
Immature immune system - structures close together lends to easy spreading from on area to another.
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)

35. Nursing dx provides basis of
Medical
Viral infection
To simulate eating motions with the hands
Interventions for which the nurse is accountable

36. The basis for a plan of care comes for which stage of the nursing process?
Pain on inspiration and expiration; superficial squeaking or grating
Stroke volume x's heart rate
Nursing dx
Assess over all health status and identify the problem

37. What are Piaget's stages of cognitive development
Double check equip and patient
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
Nursing dx
School age childen

38. 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
Decision assessment
Double check equip and patient
Focused

39. What does CAM stand for
Confusion Assessment Method
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
The process of storing - learning - retrieving - and using info.
To simulate eating motions with the hands

40. What is a definition of a delusion?
Level of stress - risk for violence - anxiety level - patient unmet needs
# of packs per day x # of years smoked
A false - fixed belief that cannot be corrected through reasoning.
Capillaries

41. What is responsible for transporting O2 in the blood
Hemoglobin
Secondary soureces (family - friends)
Fast and deep respirations seen in patient's with acidosis
Double check equip and patient

42. What is the difference between a nursing dx and a med dx?
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Non - opiod (ex: NSAID/acetominaphen)
Implementation

43. One way to test a person's cognitive ability and abstract thinking ability would be to
Having to use more than one pillow when sleeping
ID'ing status of exisiting problems and locating new issues
Have them do simple math problems
The process of storing - learning - retrieving - and using info.

44. Orthopnea is described as?
Having to use more than one pillow when sleeping
Trauma or illness
Decreased arterial perfusion
Pain

45. An example of a primary source is
Capillaries
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
The patient
Hemoglobin

46. What is the correct approach when dealing with older adults?
Implementation
Inattention and acute increase/decrease in cognitive function
Pain on inspiration and expiration; superficial squeaking or grating
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response

47. Side effects of putting confused pts in restraints include
An 80 y/o patient that has emergency surgery
Ongoing assessment
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Double check equip and patient

48. Data validation assures
Tricuspid - mitral and the aortic
The result is accurate patient dB
Interventions for which the nurse is accountable
To ID the problem

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

50. Inspiration sounds are heard longer than expiration sounds In What area?
Pain in legs assoc w walking
Fast and deep respirations seen in patient's with acidosis
Upper airways
Vesicular (peripheral lung areas)