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. The purpose of an initial assessment is
To ID the problem
Sensory motor
Initial assessment
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve


2. When using restraints in a confused patient
Risk of falls increases
Serves to expedite dx and tx of actual and potential health problems
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Defining a baseline of cognitive function - any changes or deviations from norm.


3. Intermittent claudication is caused by?
Decreased arterial perfusion
Capillaries
Pt's underlying feelings
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins


4. An example of a secondary source is
Risk of falls increases
Nursing
Family - spouse - someone other than a healthcare worker - previous medical records.
Pain


5. When performing an interview with a patient with vision loss - select the correct questions for obtaining an accurate vision history
An 80 y/o patient that has emergency surgery
Having to use more than one pillow when sleeping
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)


6. Name the 5 'W's' of assessing a change in LOC
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
Assess over all health status and identify the problem
Level of stress - risk for violence - anxiety level - patient unmet needs
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)


7. If an abnormal finding is revealed during assessment - the nurse should
Double check equip and patient
Confusion Assessment Method
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Disorganized thinking and altered LOC


8. Ageusia is
Fast and deep respirations seen in patient's with acidosis
Double check equip and patient
Risk of falls increases
Loss of taste


9. 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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10. Acceptable sources of assessment data when evaluating a confused patient would be
Hygeine - DOB - work hx
Decreased sense of taste
Capillaries
Secondary soureces (family - friends)


11. The purpose of an intitial assement serves to?
Assess over all health status and identify the problem
Hygeine - DOB - work hx
Adolescence
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.


12. Side effects of putting confused pts in restraints include
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Trauma or illness
Stroke volume x's heart rate
Implementation


13. Keeping patient's belongings - shoes - suitcases and street clothes - etc. out of view are helpful for preventing: wandering?
Objective
Wandering
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Paradoxical reaction


14. What is the nursing process?
Disorganized thinking and altered LOC
Abstract thinking
Adolescence
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.


15. What is responsible for transporting O2 in the blood
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
Adolescence
Hemoglobin
The result is accurate patient dB


16. The order of air flow into the lungs is
A false - fixed belief that cannot be corrected through reasoning.
Nursing dx
EdFED- Q
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli


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

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18. Ongoing assessments are useful in

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19. A patient that is dying is on morphine. The family is concerned the prs breathing will stop. What is the correct RN response?

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20. Describe the purpose of a mental status exam
Defining a baseline of cognitive function - any changes or deviations from norm.
Upper airways
Tricuspid - mitral and the aortic
Pain


21. Diabetes is a _________ dx
# of packs per day x # of years smoked
Medical
Trend assessment (shift report)
Pain in legs assoc w walking


22. The path of blood from the heart to the lungs is
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Ongoing assessment
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins


23. Nursing dx provides basis of
Interventions for which the nurse is accountable
An 80 y/o patient that has emergency surgery
Adolescence
Daily


24. What is the correct approach when dealing with older adults?
Upper airways
Trauma or illness
Snap - crackle - pops; velcro - bubble wrap
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response


25. Two indicators that are REQUIRED for classification via the CAM tool include
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Family - spouse - someone other than a healthcare worker - previous medical records.
Pain
Inattention and acute increase/decrease in cognitive function


26. What would cause changes in congitive development later in life (middle adulthood)?
Trauma or illness
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Preschool is cause and effect - school age begins to use logical thought process.
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.


27. What factors may indicate plural rub?
Pain on inspiration and expiration; superficial squeaking or grating
Maslow
Symptoms
Non - opiod (ex: NSAID/acetominaphen)


28. 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
Trend assessment (shift report)
Hemoglobin
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.


29. The fifth vital sign is
Risk of falls increases
Pain
Trend assessment (shift report)
Tricuspid - mitral and the aortic


30. Data from the last 24/48 hours that included patterns would be a part of
Trend assessment (shift report)
Loss of taste
Hearing loss
Immature immune system - structures close together lends to easy spreading from on area to another.


31. When a patient has increased neutrophils - this may indicate what?
Bacterial infection
Having to use more than one pillow when sleeping
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Broncial (heard over trachea)


32. At What age do you begin to use logical thought process?
The medication will not affect the patient's breathing.
Hygeine - DOB - work hx
School age childen
Decreased arterial perfusion


33. Are changes in vital signs a reliable indicator of chronic pain?
Vesicular (peripheral lung areas)
Stroke volume x's heart rate
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
No


34. What are Piaget's stages of cognitive development
Preschool is cause and effect - school age begins to use logical thought process.
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
Upper airways
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.


35. Another term for a focused assessment is
Ongoing assessment
Focused
Decreased arterial perfusion
An 80 y/o patient that has emergency surgery


36. Where can you hear bronchovesicular breath sounds?
Decreased arterial perfusion
Interventions for which the nurse is accountable
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Bacterial infection


37. Expiration sounds are heard longer than inspiration In What area?
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Broncial (heard over trachea)
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
EdFED- Q


38. What is a definition of a delusion?
A false - fixed belief that cannot be corrected through reasoning.
Secondary soureces (family - friends)
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.


39. What scale is used to determine eating and feeding issues in adults with confusion
EdFED- Q
Abstract thinking
Knowing What to do/how to make a decision based upon available data.
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -


40. What is the formula for cardiac output?

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41. An infant is in which Paiget stage?
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Sensory motor
Focused
Pain on inspiration and expiration; superficial squeaking or grating


42. One way to test a person's cognitive ability and abstract thinking ability would be to
EdFED- Q
Having to use more than one pillow when sleeping
Have them do simple math problems
Capillaries


43. Factors that may reduce the efficacy of pulse oximetry include
Secondary
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Immature immune system - structures close together lends to easy spreading from on area to another.


44. Examples of personal information
Hygeine - DOB - work hx
Communicate using hands and eyes.
Maslow
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.


45. Data that is recorded for an immediate need (code blue or fall) would be included in
Defining a baseline of cognitive function - any changes or deviations from norm.
Preschool is cause and effect - school age begins to use logical thought process.
The process of storing - learning - retrieving - and using info.
Decision assessment


46. What is the difference between a nursing dx and a med dx?
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
No
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
The result is accurate patient dB


47. A nursing dx is best described as
Ask - Believe - Choose - Deliver - Empower
Vesicular (peripheral lung areas)
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
Double check equip and patient


48. The basis for a plan of care comes for which stage of the nursing process?
Nursing dx
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Sensory motor
Decreased arterial perfusion


49. In Which part of the nursing process will you find delegation?
Nursing
Toddler
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Implementation


50. At patient that state their shoes are tighter at the end of the day may be experiencing
Edema
Trauma or illness
No
Decision assessment