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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. A nursing dx is best described as
Tricuspid - mitral and the aortic
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)
Hygeine - DOB - work hx

2. Examples of personal information
Interventions for which the nurse is accountable
Bacterial infection
Have them do simple math problems
Hygeine - DOB - work hx

3. All body system data is not necessary which type of assessment
Focused
Assess over all health status and identify the problem
Decreased arterial perfusion
Trend assessment (shift report)

4. What is the correct approach when dealing with older adults?
The medication will not affect the patient's breathing.
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
A false - fixed belief that cannot be corrected through reasoning.
Pain on inspiration and expiration; superficial squeaking or grating

5. When speaking with a patient with moderate hearing loss the RN should
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Communicate using hands and eyes.
Wandering
Edema

6. The fifth vital sign is
Capillaries
Medical
Pain
Viral infection

7. A patient failing to answer questions or displaying a reluctance to participate in group or family activities may be experiencing
Hearing loss
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
Interventions for which the nurse is accountable
Broncial (heard over trachea)

8. One way to test a person's cognitive ability and abstract thinking ability would be to
Loss of taste
Double check equip and patient
8.4
Have them do simple math problems

9. QUESTT is a tool for What type of an assessment?
Pain
Implementation
A false - fixed belief that cannot be corrected through reasoning.
Serves to expedite dx and tx of actual and potential health problems

10. When noticing a patient with dementia has stopped eating - the RN's first response is?
Interventions for which the nurse is accountable
To simulate eating motions with the hands
Immature immune system - structures close together lends to easy spreading from on area to another.
Daily

11. Another term for a focused assessment is
Pain in legs assoc w walking
Ongoing assessment
An 80 y/o patient that has emergency surgery
Pain

12. What would cause changes in congitive development later in life (middle adulthood)?
Capillaries
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Stroke volume x's heart rate
Trauma or illness

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

14. At patient that state their shoes are tighter at the end of the day may be experiencing
Edema
A personal experience that does whatever the person in pain says it does
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
Pt's with oxygenation and perfusion problems

15. When a patient has increased neutrophils - this may indicate what?
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
Bacterial infection
Non - opiod (ex: NSAID/acetominaphen)
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital

16. The path of blood from the lungs to the heart is
Objective
A personal experience that does whatever the person in pain says it does
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Double check equip and patient

17. An infant is in which Paiget stage?
Daily
ID'ing status of exisiting problems and locating new issues
Sensory motor
Decreased sense of taste

18. Why are young children at greater risk for respiratory infection?
A false - fixed belief that cannot be corrected through reasoning.
Immature immune system - structures close together lends to easy spreading from on area to another.
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

19. Are changes in vital signs a reliable indicator of chronic pain?
Inattention and acute increase/decrease in cognitive function
No
Trend assessment (shift report)
Ask - Believe - Choose - Deliver - Empower

20. An example of a nursing dx would be
The medication will not affect the patient's breathing.
Fluid volume deficit related to poor intake
Interventions for which the nurse is accountable
Non - opiod (ex: NSAID/acetominaphen)

21. Types of hearing loss include
Toddler
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
Hygeine - DOB - work hx
Irregular respirations (fast/slow) often seen at end of life

22. Asking a patient what would you do if there is a fire in the wastebasket - is a way to assess their
Serves to expedite dx and tx of actual and potential health problems
Maslow
Abstract thinking
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts

23. The purpose of an intitial assement serves to?
Irregular respirations (fast/slow) often seen at end of life
Decision assessment
A personal experience that does whatever the person in pain says it does
Assess over all health status and identify the problem

24. An ongoing assessment is performed
Daily
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Surgically implanted device for deaf or hard or hearing - also called bionic ear.

25. An example of a secondary source is
Daily
Edema
Pain in legs assoc w walking
Family - spouse - someone other than a healthcare worker - previous medical records.

26. Fluid volume deficit is a __________ dx
Having to use more than one pillow when sleeping
Nursing
Fast and deep respirations seen in patient's with acidosis
Irregular respirations (fast/slow) often seen at end of life

27. What factors may indicate plural rub?
Pain on inspiration and expiration; superficial squeaking or grating
Sensory motor
The medication will not affect the patient's breathing.
Capillaries

28. Nursing dx provides basis of
The result is accurate patient dB
Fluid volume deficit related to poor intake
To ID the problem
Interventions for which the nurse is accountable

29. At What age do you begin to use logical thought process?
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Vesicular (peripheral lung areas)
8.4
School age childen

30. Two indicators that are REQUIRED for classification via the CAM tool include
Ask - Believe - Choose - Deliver - Empower
A false - fixed belief that cannot be corrected through reasoning.
Hygeine - DOB - work hx
Inattention and acute increase/decrease in cognitive function

31. Where can wheezes best be heard?
Upper airways
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Bacterial infection
Symptoms

32. Which patient would be most likely to experience sensory overload?
An 80 y/o patient that has emergency surgery
Decision assessment
Risk of falls increases
Pain on inspiration and expiration; superficial squeaking or grating

33. What is a component of the cognitive part of critical thinking skills?
Hemoglobin
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Knowing What to do/how to make a decision based upon available data.
Secondary

34. When performing an interview with a patient with vision loss - select the correct questions for obtaining an accurate vision history
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Pain
Risk of falls increases

35. Other factors that may indicate confusion using the CAM tool could be
Level of stress - risk for violence - anxiety level - patient unmet needs
Disorganized thinking and altered LOC
An 80 y/o patient that has emergency surgery
Decision assessment

36. What are the ABCDE's of pain management?
Nursing dx
Sensory motor
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
Ask - Believe - Choose - Deliver - Empower

37. What are the components of a mental status exam that are not part of a regular assessment?
Wandering
A personal experience that does whatever the person in pain says it does
Secondary
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances

38. If an abnormal finding is revealed during assessment - the nurse should
Tricuspid - mitral and the aortic
Double check equip and patient
Preschool is cause and effect - school age begins to use logical thought process.
Trend assessment (shift report)

39. The path of blood from the heart to the lungs is
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Immature immune system - structures close together lends to easy spreading from on area to another.
No
Disorganized thinking and altered LOC

40. Data validation assures
The patient
Objective
Decreased arterial perfusion
The result is accurate patient dB

41. What is the difference between hallucination and delirium?
Decision assessment
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Trauma or illness
Disorganized thinking and altered LOC

42. Describe the purpose of a mental status exam
Defining a baseline of cognitive function - any changes or deviations from norm.
Maslow
Trend assessment (shift report)
Viral infection

43. An example of a primary source is
The patient
Nurse
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Nursing

44. When a patient has increased lymphocytes - this may indicate what?
Upper airways
Viral infection
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
Medical

45. Intermittent claudication is caused by?
ID'ing status of exisiting problems and locating new issues
Pain
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
Decreased arterial perfusion

46. The assessment that includes the patient's overhall health status
Double check equip and patient
Initial assessment
Stroke volume x's heart rate
Nursing

47. Orthopnea is described as?
Trauma or illness
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Irregular respirations (fast/slow) often seen at end of life
Having to use more than one pillow when sleeping

48. If patient reports pain of 3 on scale of 0-10 - What is the appropriate class of pain reliever?
A personal experience that does whatever the person in pain says it does
Non - opiod (ex: NSAID/acetominaphen)
The result is accurate patient dB
Decreased sense of taste

49. Side effects of putting confused pts in restraints include
Broncial (heard over trachea)
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Irregular respirations (fast/slow) often seen at end of life
Surgically implanted device for deaf or hard or hearing - also called bionic ear.

50. What is cognition?
The process of storing - learning - retrieving - and using info.
Decision assessment
Family - spouse - someone other than a healthcare worker - previous medical records.
Double check equip and patient