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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 difference between hallucination and delirium?
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Loss of taste
Ongoing assessment
Hygeine - DOB - work hx

2. What is the difference between a nursing dx and a med dx?
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
Pt's with oxygenation and perfusion problems
Initial assessment

3. Name the 5 'W's' of assessing a change in LOC
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
The process of storing - learning - retrieving - and using info.
Pt's with oxygenation and perfusion problems
Broncial (heard over trachea)

4. What is intermittent claudication?
Interventions for which the nurse is accountable
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Toddler
Pain in legs assoc w walking

5. The assessment that includes the patient's overhall health status
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Initial assessment
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Snap - crackle - pops; velcro - bubble wrap

6. Fluid volume deficit is a __________ dx
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Nursing
Secondary soureces (family - friends)

7. When noticing a patient with dementia has stopped eating - the RN's first response is?
Edema
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Immature immune system - structures close together lends to easy spreading from on area to another.
To simulate eating motions with the hands

8. Would a nursing dx be part of the primary or secondary dx?
Pain
Secondary
Pain in legs assoc w walking
Edema

9. What factors may indicate plural rub?
Edema
Pain on inspiration and expiration; superficial squeaking or grating
Have them do simple math problems
Pain

10. QUESTT is a tool for What type of an assessment?
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Knowing What to do/how to make a decision based upon available data.
Pain
Toddler

11. What would cause changes in congitive development later in life (middle adulthood)?
Trauma or illness
Bacterial infection
Having to use more than one pillow when sleeping
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)

12. An ongoing assessment is performed
Daily
Symptoms
Toddler
Immature immune system - structures close together lends to easy spreading from on area to another.

13. The path of blood from the lungs to the heart is
Have them do simple math problems
Broncial (heard over trachea)
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Medical

14. 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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15. All body system data is not necessary which type of assessment
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
# of packs per day x # of years smoked
A false - fixed belief that cannot be corrected through reasoning.
Focused

16. What is a chochlear implant?
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Decreased arterial perfusion
The medication will not affect the patient's breathing.

17. Once a medical dx has been made - who is accountable for the reporting s/s of complications?
Implementation
Decreased sense of taste
Edema
Nurse

18. In Which part of the nursing process will you find delegation?
Edema
Implementation
Learning - memory and adaptation to stress
Focused

19. Data from the last 24/48 hours that included patterns would be a part of
To simulate eating motions with the hands
Level of stress - risk for violence - anxiety level - patient unmet needs
Preschool is cause and effect - school age begins to use logical thought process.
Trend assessment (shift report)

20. Where can you hear bronchovesicular breath sounds?
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Pain
Pt's with oxygenation and perfusion problems

21. Nursing dx provides basis of
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Interventions for which the nurse is accountable
Daily

22. What does CAM stand for
Confusion Assessment Method
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Edema
Capillaries

23. What are the steps of the nursing process?
An 80 y/o patient that has emergency surgery
Hemoglobin
Ask - Believe - Choose - Deliver - Empower
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation

24. Two indicators that are REQUIRED for classification via the CAM tool include
Inattention and acute increase/decrease in cognitive function
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Decreased sense of taste
Pain

25. Data gathered via instrumention (pulse ox) is considered
To ID the problem
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Objective
Communicate using hands and eyes.

26. Are changes in vital signs a reliable indicator of chronic pain?
Learning - memory and adaptation to stress
No
Knowing What to do/how to make a decision based upon available data.
Bacterial infection

27. Side effects of putting confused pts in restraints include
Sensory motor
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Serves to expedite dx and tx of actual and potential health problems
EdFED- Q

28. One way to test a person's cognitive ability and abstract thinking ability would be to
An 80 y/o patient that has emergency surgery
Implementation
Have them do simple math problems
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)

29. A patient failing to answer questions or displaying a reluctance to participate in group or family activities may be experiencing
Inattention and acute increase/decrease in cognitive function
Irregular respirations (fast/slow) often seen at end of life
Hearing loss
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital

30. What is the correct approach when dealing with older adults?
Paradoxical reaction
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Level of stress - risk for violence - anxiety level - patient unmet needs
Trauma or illness

31. The site where gas exchange occurs is
Medical
Capillaries
A false - fixed belief that cannot be corrected through reasoning.
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances

32. Ongoing assessments are useful in

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33. The path of blood from the heart to the lungs is
Capillaries
Non - opiod (ex: NSAID/acetominaphen)
Viral infection
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins

34. Types of hearing loss include
Broncial (heard over trachea)
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Pt's underlying feelings
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. An example of a primary source is
Fluid volume deficit related to poor intake
The patient
Serves to expedite dx and tx of actual and potential health problems
Hemoglobin

36. Intermittent claudication is caused by?
Nurse
Irregular respirations (fast/slow) often seen at end of life
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Decreased arterial perfusion

37. Where can wheezes best be heard?
The medication will not affect the patient's breathing.
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
Upper airways
A false - fixed belief that cannot be corrected through reasoning.

38. Why are young children at greater risk for respiratory infection?
Loss of taste
Immature immune system - structures close together lends to easy spreading from on area to another.
A personal experience that does whatever the person in pain says it does
Knowing What to do/how to make a decision based upon available data.

39. The order of air flow into the lungs is
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
No
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins

40. When using restraints in a confused patient
Vesicular (peripheral lung areas)
Risk of falls increases
Trauma or illness
Family - spouse - someone other than a healthcare worker - previous medical records.

41. An infant is in which Paiget stage?
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
ID'ing status of exisiting problems and locating new issues
Sensory motor
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -

42. The fifth vital sign is
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
Pain
8.4
Ongoing assessment

43. What is responsible for transporting O2 in the blood
Double check equip and patient
Hygeine - DOB - work hx
Hemoglobin
Loss of taste

44. A nursing dx is best described as
Pt's with oxygenation and perfusion problems
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
Double check equip and patient
Daily

45. When performing an ongoing assessment for a patient with disturbed thinking the nurse should be sure to include
Risk of falls increases
The process of storing - learning - retrieving - and using info.
Level of stress - risk for violence - anxiety level - patient unmet needs
Viral infection

46. What do rales sound like?
Snap - crackle - pops; velcro - bubble wrap
A false - fixed belief that cannot be corrected through reasoning.
Pain in legs assoc w walking
Knowing What to do/how to make a decision based upon available data.

47. Data that is recorded for an immediate need (code blue or fall) would be included in
Bacterial infection
Decision assessment
An 80 y/o patient that has emergency surgery
Hygeine - DOB - work hx

48. Kussamaul respirations describe

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49. A patient that is easily fatigued may have a HgB lab value of?
Loss of taste
Pt's underlying feelings
Ongoing assessment
8.4

50. What are the components of a mental status exam that are not part of a regular assessment?
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
To ID the problem
Objective
Have them do simple math problems