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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. What are the components of a mental status exam that are not part of a regular assessment?
Communicate using hands and eyes.
Wandering
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
Sensory motor

2. Blood passes through the heart valves In what order?
Learning - memory and adaptation to stress
Tricuspid - mitral and the aortic
EdFED- Q
Interventions for which the nurse is accountable

3. At What age do you begin to put thoughts into words?
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 soureces (family - friends)
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Toddler

4. An infant is in which Paiget stage?
Daily
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
To simulate eating motions with the hands
Sensory motor

5. What is pain?
A personal experience that does whatever the person in pain says it does
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Secondary
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)

6. Intermittent claudication is caused by?
Maslow
Decreased arterial perfusion
Wandering
Risk of falls increases

7. Factors that may reduce the efficacy of pulse oximetry include
Pain
Family - spouse - someone other than a healthcare worker - previous medical records.
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation

8. Acceptable sources of assessment data when evaluating a confused patient would be
Pain
Communicate using hands and eyes.
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Secondary soureces (family - friends)

9. 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 -
Inattention and acute increase/decrease in cognitive function
Pain
Assess over all health status and identify the problem

10. Which patient would be most likely to experience sensory overload?
# of packs per day x # of years smoked
An 80 y/o patient that has emergency surgery
Ongoing assessment
The patient

11. If an abnormal finding is revealed during assessment - the nurse should
Double check equip and patient
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Trend assessment (shift report)
Broncial (heard over trachea)

12. What do rales sound like?
School age childen
Snap - crackle - pops; velcro - bubble wrap
Defining a baseline of cognitive function - any changes or deviations from norm.
Inattention and acute increase/decrease in cognitive function

13. Other factors that may indicate confusion using the CAM tool could be
An 80 y/o patient that has emergency surgery
Implementation
Disorganized thinking and altered LOC
A personal experience that does whatever the person in pain says it does

14. Examples of personal information
Hemoglobin
Double check equip and patient
Hygeine - DOB - work hx
Defining a baseline of cognitive function - any changes or deviations from norm.

15. Diabetes is a _________ dx
Medical
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)

16. The path of blood from the lungs to the heart is
Capillaries
# of packs per day x # of years smoked
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts

17. Orthopnea is described as?
Tricuspid - mitral and the aortic
Pt's underlying feelings
Confusion Assessment Method
Having to use more than one pillow when sleeping

18. Nursing dx provides basis of
Preschool is cause and effect - school age begins to use logical thought process.
Interventions for which the nurse is accountable
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
Surgically implanted device for deaf or hard or hearing - also called bionic ear.

19. The fifth vital sign is
Vesicular (peripheral lung areas)
Pain
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Preschool is cause and effect - school age begins to use logical thought process.

20. An example of a primary source is
Medical
The patient
Trauma or illness
Paradoxical reaction

21. What is a definition of a delusion?
A false - fixed belief that cannot be corrected through reasoning.
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Ask - Believe - Choose - Deliver - Empower
Capillaries

22. Would a nursing dx be part of the primary or secondary dx?
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Secondary
Disorganized thinking and altered LOC
EdFED- Q

23. 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.
Implementation
Medical
Nursing dx

24. Where can you hear bronchovesicular breath sounds?
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Trend assessment (shift report)
Decreased arterial perfusion
Trauma or illness

25. What is intermittent claudication?
Pain in legs assoc w walking
Ongoing assessment
Toddler
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.

26. What are Piaget's stages of cognitive development
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
Pain on inspiration and expiration; superficial squeaking or grating
Defining a baseline of cognitive function - any changes or deviations from norm.
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)

27. At patient that state their shoes are tighter at the end of the day may be experiencing
Vesicular (peripheral lung areas)
Edema
Nursing
Level of stress - risk for violence - anxiety level - patient unmet needs

28. An ongoing assessment is performed
Daily
Decreased sense of taste
Ongoing assessment
EdFED- Q

29. What is the formula for cardiac output?

30. When speaking with a patient with moderate hearing loss the RN should
Communicate using hands and eyes.
Inattention and acute increase/decrease in cognitive function
Nursing
Adolescence

31. Side effects of putting confused pts in restraints include
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Implementation
Trend assessment (shift report)
Fast and deep respirations seen in patient's with acidosis

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

33. In Which part of the nursing process will you find delegation?
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Implementation
Having to use more than one pillow when sleeping
Pain

34. What is responsible for transporting O2 in the blood
Secondary
Hemoglobin
Ongoing assessment
Focused

35. Describe the purpose of a mental status exam
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Defining a baseline of cognitive function - any changes or deviations from norm.
Tricuspid - mitral and the aortic
Stroke volume x's heart rate

36. What scale is used to determine eating and feeding issues in adults with confusion
Paradoxical reaction
Assess over all health status and identify the problem
EdFED- Q
Surgically implanted device for deaf or hard or hearing - also called bionic ear.

37. Types of hearing loss include
Focused
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
Having to use more than one pillow when sleeping
Inattention and acute increase/decrease in cognitive function

38. When a patient has increased lymphocytes - this may indicate what?
EdFED- Q
Abstract thinking
Having to use more than one pillow when sleeping
Viral infection

39. What factors may indicate plural rub?
Pain on inspiration and expiration; superficial squeaking or grating
No
Initial assessment
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy

40. The purpose of an initial assessment is
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
To ID the problem
Loss of taste
Have them do simple math problems

41. Data from the last 24/48 hours that included patterns would be a part of
Trend assessment (shift report)
Decreased sense of taste
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
Daily

42. When performing an interview with a patient with vision loss - select the correct questions for obtaining an accurate vision history
Sensory motor
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
The medication will not affect the patient's breathing.
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins

43. Ageusia is
Serves to expedite dx and tx of actual and potential health problems
Loss of taste
Paradoxical reaction
Nursing dx

44. A patient failing to answer questions or displaying a reluctance to participate in group or family activities may be experiencing
Confusion Assessment Method
The process of storing - learning - retrieving - and using info.
Hearing loss
EdFED- Q

45. Nursing interventions should be based on who's theory?
Learning - memory and adaptation to stress
Maslow
Symptoms
The patient

46. Subjective data could include
Symptoms
The process of storing - learning - retrieving - and using info.
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Double check equip and patient

47. Keeping patient's belongings - shoes - suitcases and street clothes - etc. out of view are helpful for preventing: wandering?
Wandering
Implementation
Abstract thinking
The result is accurate patient dB

48. What are the steps of the nursing process?
Irregular respirations (fast/slow) often seen at end of life
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Trauma or illness
Objective

49. Are changes in vital signs a reliable indicator of chronic pain?
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
No
Upper airways
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts

50. Once a medical dx has been made - who is accountable for the reporting s/s of complications?
Vesicular (peripheral lung areas)
Nurse
Paradoxical reaction
Trauma or illness