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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. Intermittent claudication is caused by?
Decreased arterial perfusion
Risk of falls increases
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Decision assessment

2. Sleep deprivation can effect
No
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Learning - memory and adaptation to stress
Family - spouse - someone other than a healthcare worker - previous medical records.

3. Examples of personal information
Hygeine - DOB - work hx
ID'ing status of exisiting problems and locating new issues
Defining a baseline of cognitive function - any changes or deviations from norm.
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -

4. Are changes in vital signs a reliable indicator of chronic pain?
The process of storing - learning - retrieving - and using info.
Secondary
No
Confusion Assessment Method

5. Two indicators that are REQUIRED for classification via the CAM tool include
Maslow
Edema
Adolescence
Inattention and acute increase/decrease in cognitive function

6. Expiration sounds are heard longer than inspiration In What area?
Broncial (heard over trachea)
Loss of taste
8.4
Secondary

7. Other factors that may indicate confusion using the CAM tool could be
The medication will not affect the patient's breathing.
Disorganized thinking and altered LOC
Pain on inspiration and expiration; superficial squeaking or grating
# of packs per day x # of years smoked

8. What are Piaget's stages of cognitive development
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Implementation
Trauma or illness
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)

9. If patient reports pain of 3 on scale of 0-10 - What is the appropriate class of pain reliever?
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Having to use more than one pillow when sleeping
Nurse
Non - opiod (ex: NSAID/acetominaphen)

10. An infant is in which Paiget stage?
Snap - crackle - pops; velcro - bubble wrap
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
No
Sensory motor

11. What is a definition of a delusion?
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Pain
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
A false - fixed belief that cannot be corrected through reasoning.

12. When performing an ongoing assessment for a patient with disturbed thinking the nurse should be sure to include
Level of stress - risk for violence - anxiety level - patient unmet needs
Assess over all health status and identify the problem
Upper airways
The patient

13. 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)
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Pain in legs assoc w walking
Secondary soureces (family - friends)

14. Describe the purpose of a mental status exam
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
The result is accurate patient dB
Defining a baseline of cognitive function - any changes or deviations from norm.

15. What are the ABCDE's of pain management?
Fast and deep respirations seen in patient's with acidosis
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Ask - Believe - Choose - Deliver - Empower
A false - fixed belief that cannot be corrected through reasoning.

16. An example of a secondary source is
Decreased sense of taste
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.
Have them do simple math problems

17. Kussamaul respirations describe

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18. What is the formula for determining pack years?
# of packs per day x # of years smoked
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
Pain in legs assoc w walking
Non - opiod (ex: NSAID/acetominaphen)

19. Diabetes is a _________ dx
Hemoglobin
Having to use more than one pillow when sleeping
Hearing loss
Medical

20. Subjective data could include
Pt's underlying feelings
Symptoms
Snap - crackle - pops; velcro - bubble wrap
No

21. What would cause changes in congitive development later in life (middle adulthood)?
Nursing
Trauma or illness
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Irregular respirations (fast/slow) often seen at end of life

22. What are the components of an assessment?
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Confusion Assessment Method
The patient
Data collection - data validation - data organization - data analysis - and data reporting/recording.

23. What is the cognitive difference between a preschooler and schoolage child?
ID'ing status of exisiting problems and locating new issues
Nursing
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
Preschool is cause and effect - school age begins to use logical thought process.

24. If an abnormal finding is revealed during assessment - the nurse should
Immature immune system - structures close together lends to easy spreading from on area to another.
Double check equip and patient
A false - fixed belief that cannot be corrected through reasoning.
The patient

25. The assessment that includes the patient's overhall health status
Broncial (heard over trachea)
Initial assessment
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.

26. What are the steps of the nursing process?
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Nurse
Fluid volume deficit related to poor intake
To ID the problem

27. What scale is used to determine eating and feeding issues in adults with confusion
Risk of falls increases
Fast and deep respirations seen in patient's with acidosis
Interventions for which the nurse is accountable
EdFED- Q

28. The purpose of an intitial assement serves to?
Hygeine - DOB - work hx
Fast and deep respirations seen in patient's with acidosis
Assess over all health status and identify the problem
Pain in legs assoc w walking

29. When a patient has increased lymphocytes - this may indicate what?
Tricuspid - mitral and the aortic
Level of stress - risk for violence - anxiety level - patient unmet needs
Viral infection
A personal experience that does whatever the person in pain says it does

30. 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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31. A nursing dx is best described as
Paradoxical reaction
Pain
Loss of taste
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.

32. Side effects of putting confused pts in restraints include
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Capillaries
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy

33. Acceptable sources of assessment data when evaluating a confused patient would be
Disorganized thinking and altered LOC
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)

34. Data validation assures
The result is accurate patient dB
Ongoing assessment
The patient
Communicate using hands and eyes.

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

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36. What do rhonchi sound like?
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Edema
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts

37. What factors may indicate plural rub?
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Snap - crackle - pops; velcro - bubble wrap
Pain on inspiration and expiration; superficial squeaking or grating
Capillaries

38. Why are young children at greater risk for respiratory infection?
Having to use more than one pillow when sleeping
Immature immune system - structures close together lends to easy spreading from on area to another.
Edema
Assess over all health status and identify the problem

39. What is responsible for transporting O2 in the blood
Hemoglobin
Upper airways
EdFED- Q
Vesicular (peripheral lung areas)

40. When speaking with a patient with moderate hearing loss the RN should
Communicate using hands and eyes.
No
Toddler
Vesicular (peripheral lung areas)

41. Data gathered via instrumention (pulse ox) is considered
Hemoglobin
Objective
Risk of falls increases
Double check equip and patient

42. Where can you hear bronchovesicular breath sounds?
School age childen
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
No
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.

43. Types of hearing loss include
A false - fixed belief that cannot be corrected through reasoning.
ID'ing status of exisiting problems and locating new issues
Decision assessment
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)

44. Asking a patient what would you do if there is a fire in the wastebasket - is a way to assess their
Pain
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Abstract thinking
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve

45. One way to test a person's cognitive ability and abstract thinking ability would be to
Maslow
Have them do simple math problems
Symptoms
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.

46. At What age do you begin to use logical thought process?
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
No
School age childen
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy

47. The fifth vital sign is
Fluid volume deficit related to poor intake
Defining a baseline of cognitive function - any changes or deviations from norm.
Abstract thinking
Pain

48. The path of blood from the heart to the lungs is
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
The medication will not affect the patient's breathing.
Ask - Believe - Choose - Deliver - Empower
Hemoglobin

49. What is a chochlear implant?
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
Pt's with oxygenation and perfusion problems
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation

50. In Which part of the nursing process will you find delegation?
Implementation
Disorganized thinking and altered LOC
Abstract thinking
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.