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Nursing Fundamentals 3

Instructions:

Answer 50 questions in 15 minutes.
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Match each statement with the correct term.
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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. Kussamaul respirations describe

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2. 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.
Tricuspid - mitral and the aortic
The result is accurate patient dB
Pain

3. Side effects of putting confused pts in restraints include
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Nurse
Focused

4. Ongoing assessments are useful in

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5. A patient that is easily fatigued may have a HgB lab value of?
To simulate eating motions with the hands
8.4
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
Preschool is cause and effect - school age begins to use logical thought process.

6. A potential adverse rx of chemically restraining a confused patient would be
Viral infection
Pain
Paradoxical reaction
Communicate using hands and eyes.

7. What is the formula for cardiac output?

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8. What is pain?
Daily
Implementation
A personal experience that does whatever the person in pain says it does
Abstract thinking

9. Acceptable sources of assessment data when evaluating a confused patient would be
Wandering
Secondary soureces (family - friends)
Upper airways
A personal experience that does whatever the person in pain says it does

10. If patient reports pain of 3 on scale of 0-10 - What is the appropriate class of pain reliever?
Hearing loss
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
An 80 y/o patient that has emergency surgery
Non - opiod (ex: NSAID/acetominaphen)

11. Data that is recorded for an immediate need (code blue or fall) would be included in
Ongoing assessment
Pt's with oxygenation and perfusion problems
Decision assessment
Inattention and acute increase/decrease in cognitive function

12. An example of a nursing dx would be
Abstract thinking
Double check equip and patient
Maslow
Fluid volume deficit related to poor intake

13. What are Cheyne Stokes?
The process of storing - learning - retrieving - and using info.
Nurse
Irregular respirations (fast/slow) often seen at end of life
Data collection - data validation - data organization - data analysis - and data reporting/recording.

14. What are Piaget's stages of cognitive development
Non - opiod (ex: NSAID/acetominaphen)
Irregular respirations (fast/slow) often seen at end of life
Hygeine - DOB - work hx
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)

15. When performing an interview with a patient with vision loss - select the correct questions for obtaining an accurate vision history
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
A false - fixed belief that cannot be corrected through reasoning.
Broncial (heard over trachea)

16. What would cause changes in congitive development later in life (middle adulthood)?
Family - spouse - someone other than a healthcare worker - previous medical records.
Nursing
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
Trauma or illness

17. What factors may indicate plural rub?
Symptoms
Preschool is cause and effect - school age begins to use logical thought process.
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Pain on inspiration and expiration; superficial squeaking or grating

18. What is a component of the cognitive part of critical thinking skills?
Initial assessment
Ongoing assessment
A false - fixed belief that cannot be corrected through reasoning.
Knowing What to do/how to make a decision based upon available data.

19. An ongoing assessment is performed
Toddler
Daily
Initial assessment
ID'ing status of exisiting problems and locating new issues

20. The site where gas exchange occurs is
Capillaries
Abstract thinking
An 80 y/o patient that has emergency surgery
Decision assessment

21. Data from the last 24/48 hours that included patterns would be a part of
Have them do simple math problems
Implementation
Ask - Believe - Choose - Deliver - Empower
Trend assessment (shift report)

22. Intermittent claudication is caused by?
Decreased arterial perfusion
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Confusion Assessment Method
Inattention and acute increase/decrease in cognitive function

23. An infant is in which Paiget stage?
Sensory motor
Decreased sense of taste
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Bacterial infection

24. Other factors that may indicate confusion using the CAM tool could be
Double check equip and patient
Disorganized thinking and altered LOC
Secondary
Interventions for which the nurse is accountable

25. What are the ABCDE's of pain management?
Decreased sense of taste
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
Ask - Believe - Choose - Deliver - Empower
Trend assessment (shift report)

26. At patient that state their shoes are tighter at the end of the day may be experiencing
Symptoms
To simulate eating motions with the hands
Edema
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital

27. At What age do you begin to put thoughts into words?
Toddler
Pain on inspiration and expiration; superficial squeaking or grating
8.4
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli

28. When a patient has increased neutrophils - this may indicate what?
Bacterial infection
Assess over all health status and identify the problem
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve

29. A patient failing to answer questions or displaying a reluctance to participate in group or family activities may be experiencing
Hygeine - DOB - work hx
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Hearing loss
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)

30. An example of a primary source is
Ask - Believe - Choose - Deliver - Empower
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
The patient

31. When performing an ongoing assessment for a patient with disturbed thinking the nurse should be sure to include
Vesicular (peripheral lung areas)
Level of stress - risk for violence - anxiety level - patient unmet needs
Pt's underlying feelings
Non - opiod (ex: NSAID/acetominaphen)

32. The purpose of an intitial assement serves to?
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
Confusion Assessment Method
Assess over all health status and identify the problem
Nursing dx

33. What is responsible for transporting O2 in the blood
Non - opiod (ex: NSAID/acetominaphen)
Hemoglobin
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
Initial assessment

34. Describe the purpose of a mental status exam
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Paradoxical reaction
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Defining a baseline of cognitive function - any changes or deviations from norm.

35. Fluid volume deficit is a __________ dx
Trend assessment (shift report)
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Pain
Nursing

36. What does CAM stand for
Interventions for which the nurse is accountable
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Confusion Assessment Method
Pt's underlying feelings

37. The fifth vital sign is
Pain in legs assoc w walking
Paradoxical reaction
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Pain

38. What is a definition of a delusion?
A false - fixed belief that cannot be corrected through reasoning.
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
Medical
Have them do simple math problems

39. At What age do you begin to use logical thought process?
The patient
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
School age childen
Broncial (heard over trachea)

40. The basis for a plan of care comes for which stage of the nursing process?
Having to use more than one pillow when sleeping
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)
Nursing dx

41. Ageusia is
The patient
Non - opiod (ex: NSAID/acetominaphen)
Loss of taste
An 80 y/o patient that has emergency surgery

42. When noticing a patient with dementia has stopped eating - the RN's first response is?
Pain
To simulate eating motions with the hands
No
The result is accurate patient dB

43. 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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44. One way to test a person's cognitive ability and abstract thinking ability would be to
Hygeine - DOB - work hx
Toddler
Serves to expedite dx and tx of actual and potential health problems
Have them do simple math problems

45. All body system data is not necessary which type of assessment
Paradoxical reaction
Bacterial infection
Focused
ID'ing status of exisiting problems and locating new issues

46. What are the steps of the nursing process?
Risk of falls increases
Symptoms
Edema
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation

47. What do rales sound like?
School age childen
Fluid volume deficit related to poor intake
Secondary
Snap - crackle - pops; velcro - bubble wrap

48. What do rhonchi sound like?
Implementation
Trauma or illness
Snap - crackle - pops; velcro - bubble wrap
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts

49. What are the components of an assessment?
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Ask - Believe - Choose - Deliver - Empower
Disorganized thinking and altered LOC
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)

50. Name the 5 'W's' of assessing a change in LOC
Stroke volume x's heart rate
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Interventions for which the nurse is accountable
Hygeine - DOB - work hx

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Nursing Fundamentals 3

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