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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. Describe the purpose of a mental status exam
Assess over all health status and identify the problem
Medical
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.

2. Fluid volume deficit is a __________ dx
Have them do simple math problems
Disorganized thinking and altered LOC
Loss of taste
Nursing

3. Examples of personal information
Viral infection
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
Hygeine - DOB - work hx
Have them do simple math problems

4. What is the difference between hallucination and delirium?
Assess over all health status and identify the problem
Interventions for which the nurse is accountable
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve

5. QUESTT is a tool for What type of an assessment?
Level of stress - risk for violence - anxiety level - patient unmet needs
Pain
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Edema

6. Data that is recorded for an immediate need (code blue or fall) would be included in
Knowing What to do/how to make a decision based upon available data.
Communicate using hands and eyes.
Pain on inspiration and expiration; superficial squeaking or grating
Decision assessment

7. At What age do you begin to put thoughts into words?
Knowing What to do/how to make a decision based upon available data.
An 80 y/o patient that has emergency surgery
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
Toddler

8. Acceptable sources of assessment data when evaluating a confused patient would be
Sensory motor
Secondary soureces (family - friends)
No
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.

9. The order of air flow into the lungs is
Preschool is cause and effect - school age begins to use logical thought process.
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
Tricuspid - mitral and the aortic
Sensory motor

10. What do rales sound like?
The medication will not affect the patient's breathing.
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Snap - crackle - pops; velcro - bubble wrap
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts

11. One way to test a person's cognitive ability and abstract thinking ability would be to
Risk of falls increases
Vesicular (peripheral lung areas)
Trend assessment (shift report)
Have them do simple math problems

12. What is the difference between a nursing dx and a med dx?
Having to use more than one pillow when sleeping
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Have them do simple math problems
Surgically implanted device for deaf or hard or hearing - also called bionic ear.

13. Side effects of putting confused pts in restraints include
Abstract thinking
Secondary
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.

14. An example of a nursing dx would be
A personal experience that does whatever the person in pain says it does
Fluid volume deficit related to poor intake
Viral infection
A false - fixed belief that cannot be corrected through reasoning.

15. A patient that is easily fatigued may have a HgB lab value of?
Nursing dx
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
Immature immune system - structures close together lends to easy spreading from on area to another.
8.4

16. All body system data is not necessary which type of assessment
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
Focused
Pain

17. Another term for a focused assessment is
Ongoing assessment
Nursing dx
A false - fixed belief that cannot be corrected through reasoning.
Initial assessment

18. Data validation assures
Trend assessment (shift report)
Hemoglobin
The result is accurate patient dB
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.

19. What is the purpose of the nursing process?
Serves to expedite dx and tx of actual and potential health problems
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
Level of stress - risk for violence - anxiety level - patient unmet needs

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

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21. An example of a secondary source is
Ask - Believe - Choose - Deliver - Empower
Pt's with oxygenation and perfusion problems
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
Family - spouse - someone other than a healthcare worker - previous medical records.

22. When noticing a patient with dementia has stopped eating - the RN's first response is?
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
To simulate eating motions with the hands
Initial assessment

23. Ongoing assessments are useful in

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24. The fifth vital sign is
Pain
Initial assessment
Wandering
Snap - crackle - pops; velcro - bubble wrap

25. What are Cheyne Stokes?
Irregular respirations (fast/slow) often seen at end of life
No
Paradoxical reaction
Fast and deep respirations seen in patient's with acidosis

26. Name the 5 'W's' of assessing a change in LOC
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Inattention and acute increase/decrease in cognitive function
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Secondary

27. If patient reports pain of 3 on scale of 0-10 - What is the appropriate class of pain reliever?
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Non - opiod (ex: NSAID/acetominaphen)
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Serves to expedite dx and tx of actual and potential health problems

28. What is intermittent claudication?
Daily
Pain in legs assoc w walking
Preschool is cause and effect - school age begins to use logical thought process.
Family - spouse - someone other than a healthcare worker - previous medical records.

29. Keeping patient's belongings - shoes - suitcases and street clothes - etc. out of view are helpful for preventing: wandering?
Wandering
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Vesicular (peripheral lung areas)
Daily

30. Expiration sounds are heard longer than inspiration In What area?
Wandering
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Broncial (heard over trachea)
Eye hygeine - accomodating factors - what was the level of decline - how long has it been

31. What are the steps of the nursing process?
Non - opiod (ex: NSAID/acetominaphen)
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Pain

32. In Which part of the nursing process will you find delegation?
Implementation
Pain
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

33. Sleep deprivation can effect
Irregular respirations (fast/slow) often seen at end of life
Learning - memory and adaptation to stress
EdFED- Q
Assess over all health status and identify the problem

34. The basis for a plan of care comes for which stage of the nursing process?
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Communicate using hands and eyes.
Having to use more than one pillow when sleeping
Nursing dx

35. What are the components of an assessment?
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Hemoglobin
Nursing
Pain

36. An infant is in which Paiget stage?
Having to use more than one pillow when sleeping
Hygeine - DOB - work hx
Daily
Sensory motor

37. If an abnormal finding is revealed during assessment - the nurse should
Decreased sense of taste
Double check equip and patient
Interventions for which the nurse is accountable
Capillaries

38. An example of a primary source is
Wandering
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
The patient
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.

39. Asking a patient what would you do if there is a fire in the wastebasket - is a way to assess their
Abstract thinking
Pain
Level of stress - risk for violence - anxiety level - patient unmet needs
Secondary soureces (family - friends)

40. At What age do you begin to use decision making?
Ongoing assessment
Adolescence
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Capillaries

41. What is pain?
Fast and deep respirations seen in patient's with acidosis
Ongoing assessment
A personal experience that does whatever the person in pain says it does
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)

42. What are Piaget's stages of cognitive development
Assess over all health status and identify the problem
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
Loss of taste

43. What do rhonchi sound like?
Ask - Believe - Choose - Deliver - Empower
Adolescence
Stroke volume x's heart rate
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts

44. What is the nursing process?
Tricuspid - mitral and the aortic
An 80 y/o patient that has emergency surgery
Hygeine - DOB - work hx
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.

45. What is a chochlear implant?
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Symptoms
Disorganized thinking and altered LOC
To simulate eating motions with the hands

46. Where can wheezes best be heard?
Upper airways
Hemoglobin
ID'ing status of exisiting problems and locating new issues
To simulate eating motions with the hands

47. What is the cognitive difference between a preschooler and schoolage child?
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Preschool is cause and effect - school age begins to use logical thought process.

48. What scale is used to determine eating and feeding issues in adults with confusion
Confusion Assessment Method
Decreased sense of taste
Communicate using hands and eyes.
EdFED- Q

49. What factors may indicate plural rub?
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Edema
Pain
Pain on inspiration and expiration; superficial squeaking or grating

50. What would cause changes in congitive development later in life (middle adulthood)?
Double check equip and patient
To simulate eating motions with the hands
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Trauma or illness