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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. When speaking with a patient with moderate hearing loss the RN should
Communicate using hands and eyes.
The process of storing - learning - retrieving - and using info.
The medication will not affect the patient's breathing.
To simulate eating motions with the hands

2. What are the steps of the nursing process?
A personal experience that does whatever the person in pain says it does
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Fluid volume deficit related to poor intake
Pt's with oxygenation and perfusion problems

3. Ongoing assessments are useful in

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4. The fifth vital sign is
Pain
Toddler
Daily
Hemoglobin

5. What is the difference between a nursing dx and a med dx?
Risk of falls increases
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Assess over all health status and identify the problem

6. All body system data is not necessary which type of assessment
To simulate eating motions with the hands
Fluid volume deficit related to poor intake
# of packs per day x # of years smoked
Focused

7. When performing an ongoing assessment for a patient with disturbed thinking the nurse should be sure to include
Hygeine - DOB - work hx
Level of stress - risk for violence - anxiety level - patient unmet needs
To ID the problem
# of packs per day x # of years smoked

8. An example of a secondary source is
Double check equip and patient
Family - spouse - someone other than a healthcare worker - previous medical records.
Trauma or illness
Symptoms

9. Nursing dx provides basis of
Secondary
Broncial (heard over trachea)
8.4
Interventions for which the nurse is accountable

10. A patient failing to answer questions or displaying a reluctance to participate in group or family activities may be experiencing
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Pt's underlying feelings
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Hearing loss

11. Where can wheezes best be heard?
Broncial (heard over trachea)
Upper airways
Capillaries
Assess over all health status and identify the problem

12. What is the difference between hallucination and delirium?
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -

13. Which patient would be most likely to experience sensory overload?
An 80 y/o patient that has emergency surgery
Tricuspid - mitral and the aortic
Snap - crackle - pops; velcro - bubble wrap
Nursing dx

14. A nursing dx is best described as
Knowing What to do/how to make a decision based upon available data.
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
Serves to expedite dx and tx of actual and potential health problems
8.4

15. Diabetes is a _________ dx
Ask - Believe - Choose - Deliver - Empower
Pain
Medical
Defining a baseline of cognitive function - any changes or deviations from norm.

16. What is a definition of a delusion?
Trend assessment (shift report)
To ID the problem
The patient
A false - fixed belief that cannot be corrected through reasoning.

17. If patient reports pain of 3 on scale of 0-10 - What is the appropriate class of pain reliever?
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Serves to expedite dx and tx of actual and potential health problems
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
Non - opiod (ex: NSAID/acetominaphen)

18. If an abnormal finding is revealed during assessment - the nurse should
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Double check equip and patient
Loss of taste
School age childen

19. What is a component of the cognitive part of critical thinking skills?
Initial assessment
EdFED- Q
Knowing What to do/how to make a decision based upon available data.
The result is accurate patient dB

20. Ageusia is
Wandering
Loss of taste
Pain
Irregular respirations (fast/slow) often seen at end of life

21. Data validation assures
Viral infection
Fast and deep respirations seen in patient's with acidosis
Trauma or illness
The result is accurate patient dB

22. What is the correct approach when dealing with older adults?
An 80 y/o patient that has emergency surgery
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
To ID the problem

23. What are the ABCDE's of pain management?
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
A false - fixed belief that cannot be corrected through reasoning.
Non - opiod (ex: NSAID/acetominaphen)
Ask - Believe - Choose - Deliver - Empower

24. Keeping patient's belongings - shoes - suitcases and street clothes - etc. out of view are helpful for preventing: wandering?
To ID the problem
Bacterial infection
Having to use more than one pillow when sleeping
Wandering

25. Are changes in vital signs a reliable indicator of chronic pain?
Sensory motor
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Disorganized thinking and altered LOC
No

26. Intermittent claudication is caused by?
Knowing What to do/how to make a decision based upon available data.
Decreased arterial perfusion
Decision assessment
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital

27. Types of hearing loss include
Upper airways
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
Secondary
Secondary soureces (family - friends)

28. QUESTT is a tool for What type of an assessment?
Initial assessment
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Pain
Eye hygeine - accomodating factors - what was the level of decline - how long has it been

29. Acceptable sources of assessment data when evaluating a confused patient would be
Pain in legs assoc w walking
Snap - crackle - pops; velcro - bubble wrap
Secondary soureces (family - friends)
ID'ing status of exisiting problems and locating new issues

30. An example of a primary source is
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Decreased sense of taste
The patient
Fluid volume deficit related to poor intake

31. When a patient has increased neutrophils - this may indicate what?
Trend assessment (shift report)
Bacterial infection
Decision assessment
Ongoing assessment

32. The site where gas exchange occurs is
Knowing What to do/how to make a decision based upon available data.
Capillaries
Decreased sense of taste
Wandering

33. Would a nursing dx be part of the primary or secondary dx?
Trend assessment (shift report)
Secondary
Hemoglobin
Fluid volume deficit related to poor intake

34. Factors that may reduce the efficacy of pulse oximetry include
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Capillaries
Decision assessment
Daily

35. A potential adverse rx of chemically restraining a confused patient would be
Paradoxical reaction
Risk of falls increases
8.4
Pain

36. 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)
Ask - Believe - Choose - Deliver - Empower
# of packs per day x # of years smoked
Defining a baseline of cognitive function - any changes or deviations from norm.

37. The purpose of an initial assessment is
Symptoms
To ID the problem
Pain
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -

38. What is intermittent claudication?
Loss of taste
Non - opiod (ex: NSAID/acetominaphen)
Pain in legs assoc w walking
The patient

39. At What age do you begin to use decision making?
Non - opiod (ex: NSAID/acetominaphen)
Bacterial infection
Adolescence
Pain in legs assoc w walking

40. What is the nursing process?
Decreased sense of taste
Edema
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Symptoms

41. What do rales sound like?
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
Symptoms
Pt's with oxygenation and perfusion problems
Snap - crackle - pops; velcro - bubble wrap

42. 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.
Nursing
Hygeine - DOB - work hx
Serves to expedite dx and tx of actual and potential health problems

43. An ongoing assessment is performed
Focused
Hygeine - DOB - work hx
Daily
Adolescence

44. Kussamaul respirations describe

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45. Sleep deprivation can effect
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Level of stress - risk for violence - anxiety level - patient unmet needs
Learning - memory and adaptation to stress
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation

46. Examples of personal information
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Hygeine - DOB - work hx
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve

47. What are the components of an assessment?
Assess over all health status and identify the problem
The patient
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Tricuspid - mitral and the aortic

48. Other factors that may indicate confusion using the CAM tool could be
Serves to expedite dx and tx of actual and potential health problems
Nurse
Sensory motor
Disorganized thinking and altered LOC

49. Subjective data could include
Pain
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Symptoms
Wandering

50. 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.
The process of storing - learning - retrieving - and using info.
Level of stress - risk for violence - anxiety level - patient unmet needs