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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. Asking a patient what would you do if there is a fire in the wastebasket - is a way to assess their
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Abstract thinking
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response

2. What is the purpose of the nursing process?
Hygeine - DOB - work hx
Serves to expedite dx and tx of actual and potential health problems
Secondary soureces (family - friends)
Ongoing assessment

3. Name the 5 'W's' of assessing a change in LOC
Fast and deep respirations seen in patient's with acidosis
Level of stress - risk for violence - anxiety level - patient unmet needs
Trauma or illness
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)

4. Where can you hear bronchovesicular breath sounds?
Decreased arterial perfusion
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Having to use more than one pillow when sleeping
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.

5. Ongoing assessments are useful in

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6. An example of a primary source is
Hygeine - DOB - work hx
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
The patient
Pain

7. What does CAM stand for
Edema
Confusion Assessment Method
Loss of taste
No

8. A patient failing to answer questions or displaying a reluctance to participate in group or family activities may be experiencing
Hearing loss
Pain in legs assoc w walking
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Assess over all health status and identify the problem

9. The purpose of an intitial assement serves to?
Assess over all health status and identify the problem
Secondary
Fast and deep respirations seen in patient's with acidosis
Ongoing assessment

10. Intermittent claudication is caused by?
Tricuspid - mitral and the aortic
Immature immune system - structures close together lends to easy spreading from on area to another.
Initial assessment
Decreased arterial perfusion

11. Hypogeusis is
Nursing dx
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
Decreased sense of taste
Hemoglobin

12. Subjective data could include
Symptoms
Medical
Fast and deep respirations seen in patient's with acidosis
Data collection - data validation - data organization - data analysis - and data reporting/recording.

13. An ongoing assessment is performed
Daily
Fluid volume deficit related to poor intake
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Decision assessment

14. 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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15. Would a nursing dx be part of the primary or secondary dx?
Defining a baseline of cognitive function - any changes or deviations from norm.
A false - fixed belief that cannot be corrected through reasoning.
Secondary
Edema

16. Diabetes is a _________ dx
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
An 80 y/o patient that has emergency surgery
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Medical

17. Why are young children at greater risk for respiratory infection?
Defining a baseline of cognitive function - any changes or deviations from norm.
Wandering
Nursing dx
Immature immune system - structures close together lends to easy spreading from on area to another.

18. Orthopnea is described as?
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Initial assessment
An 80 y/o patient that has emergency surgery
Having to use more than one pillow when sleeping

19. What do rhonchi sound like?
Confusion Assessment Method
Focused
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli

20. When a patient has increased lymphocytes - this may indicate what?
Communicate using hands and eyes.
Viral infection
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
Have them do simple math problems

21. What is a definition of a delusion?
A false - fixed belief that cannot be corrected through reasoning.
Fluid volume deficit related to poor intake
Medical
Trend assessment (shift report)

22. What factors may indicate plural rub?
Wandering
No
Medical
Pain on inspiration and expiration; superficial squeaking or grating

23. Data gathered via instrumention (pulse ox) is considered
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Nursing
Objective
Ongoing assessment

24. Keeping patient's belongings - shoes - suitcases and street clothes - etc. out of view are helpful for preventing: wandering?
No
Wandering
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Double check equip and patient

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

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26. A nursing dx is best described as
Daily
Defining a baseline of cognitive function - any changes or deviations from norm.
Pt's underlying feelings
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.

27. One way to test a person's cognitive ability and abstract thinking ability would be to
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Hemoglobin
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Have them do simple math problems

28. When noticing a patient with dementia has stopped eating - the RN's first response is?
Tricuspid - mitral and the aortic
ID'ing status of exisiting problems and locating new issues
To simulate eating motions with the hands
Symptoms

29. If an abnormal finding is revealed during assessment - the nurse should
Hygeine - DOB - work hx
Maslow
Double check equip and patient
Risk of falls increases

30. Acceptable sources of assessment data when evaluating a confused patient would be
Snap - crackle - pops; velcro - bubble wrap
Secondary soureces (family - friends)
EdFED- Q
Stroke volume x's heart rate

31. Sleep deprivation can effect
Trend assessment (shift report)
Learning - memory and adaptation to stress
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
Secondary soureces (family - friends)

32. When performing an ongoing assessment for a patient with disturbed thinking the nurse should be sure to include
Secondary
Level of stress - risk for violence - anxiety level - patient unmet needs
Edema
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation

33. QUESTT is a tool for What type of an assessment?
Medical
Pain
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
The patient

34. The fifth vital sign is
8.4
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Pain
Edema

35. What is the cognitive difference between a preschooler and schoolage child?
Trend assessment (shift report)
Preschool is cause and effect - school age begins to use logical thought process.
Inattention and acute increase/decrease in cognitive function
Pt's underlying feelings

36. Blood passes through the heart valves In what order?
Tricuspid - mitral and the aortic
The result is accurate patient dB
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Nursing dx

37. Expiration sounds are heard longer than inspiration In What area?
Broncial (heard over trachea)
Pain on inspiration and expiration; superficial squeaking or grating
Decreased arterial perfusion
Symptoms

38. What are Cheyne Stokes?
Irregular respirations (fast/slow) often seen at end of life
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Nursing
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)

39. The path of blood from the lungs to the heart is
Decision assessment
Serves to expedite dx and tx of actual and potential health problems
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Eye hygeine - accomodating factors - what was the level of decline - how long has it been

40. What scale is used to determine eating and feeding issues in adults with confusion
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
Hearing loss
EdFED- Q
Communicate using hands and eyes.

41. Nursing interventions should be based on who's theory?
The result is accurate patient dB
Focused
Decreased arterial perfusion
Maslow

42. Data validation assures
The result is accurate patient dB
ID'ing status of exisiting problems and locating new issues
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Ongoing assessment

43. Nursing dx provides basis of
No
Data collection - data validation - data organization - data analysis - and data reporting/recording.
A personal experience that does whatever the person in pain says it does
Interventions for which the nurse is accountable

44. What is the correct approach when dealing with older adults?
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Paradoxical reaction
Pt's with oxygenation and perfusion problems

45. In Which part of the nursing process will you find delegation?
Edema
Initial assessment
Capillaries
Implementation

46. Examples of personal information
Hygeine - DOB - work hx
To ID the problem
Learning - memory and adaptation to stress
Immature immune system - structures close together lends to easy spreading from on area to another.

47. What are the steps of the nursing process?
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Double check equip and patient
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation

48. Other factors that may indicate confusion using the CAM tool could be
Pain in legs assoc w walking
Irregular respirations (fast/slow) often seen at end of life
Family - spouse - someone other than a healthcare worker - previous medical records.
Disorganized thinking and altered LOC

49. When using restraints in a confused patient
Risk of falls increases
The patient
Confusion Assessment Method
A false - fixed belief that cannot be corrected through reasoning.

50. What are the components of an assessment?
Learning - memory and adaptation to stress
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Daily