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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. Data validation assures
Adolescence
Vesicular (peripheral lung areas)
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
The result is accurate patient dB

2. What is the formula for determining pack years?
Communicate using hands and eyes.
Irregular respirations (fast/slow) often seen at end of life
# of packs per day x # of years smoked
The result is accurate patient dB

3. When noticing a patient with dementia has stopped eating - the RN's first response is?
Communicate using hands and eyes.
To simulate eating motions with the hands
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Loss of taste

4. When speaking with a patient with moderate hearing loss the RN should
Bacterial infection
Secondary soureces (family - friends)
Learning - memory and adaptation to stress
Communicate using hands and eyes.

5. Ongoing assessments are useful in

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6. Keeping patient's belongings - shoes - suitcases and street clothes - etc. out of view are helpful for preventing: wandering?
Ask - Believe - Choose - Deliver - Empower
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Medical
Wandering

7. Diabetes is a _________ dx
Medical
Risk of falls increases
Initial assessment
Pain in legs assoc w walking

8. Other factors that may indicate confusion using the CAM tool could be
Pt's with oxygenation and perfusion problems
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 false - fixed belief that cannot be corrected through reasoning.
Disorganized thinking and altered LOC

9. What is a chochlear implant?
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Hearing loss

10. The path of blood from the lungs to the heart is
Pain on inspiration and expiration; superficial squeaking or grating
Inattention and acute increase/decrease in cognitive function
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve

11. The basis for a plan of care comes for which stage of the nursing process?
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Disorganized thinking and altered LOC
Immature immune system - structures close together lends to easy spreading from on area to another.
Nursing dx

12. Why are young children at greater risk for respiratory infection?
# of packs per day x # of years smoked
Pt's with oxygenation and perfusion problems
Loss of taste
Immature immune system - structures close together lends to easy spreading from on area to another.

13. The purpose of an initial assessment is
School age childen
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Fluid volume deficit related to poor intake
To ID the problem

14. Where can wheezes best be heard?
Upper airways
Secondary soureces (family - friends)
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)

15. Expiration sounds are heard longer than inspiration In What area?
Broncial (heard over trachea)
Interventions for which the nurse is accountable
Having to use more than one pillow when sleeping
Trend assessment (shift report)

16. Nursing dx provides basis of
Upper airways
Interventions for which the nurse is accountable
Ongoing assessment
Capillaries

17. What is the difference between a nursing dx and a med dx?
Daily
Viral infection
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Maslow

18. When a patient has increased lymphocytes - this may indicate what?
Trauma or illness
Bacterial infection
Pain on inspiration and expiration; superficial squeaking or grating
Viral infection

19. Two indicators that are REQUIRED for classification via the CAM tool include
Inattention and acute increase/decrease in cognitive function
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Fluid volume deficit related to poor intake
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -

20. The path of blood from the heart to the lungs is
Daily
To ID the problem
Wandering
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins

21. If an abnormal finding is revealed during assessment - the nurse should
Double check equip and patient
Sensory motor
Bacterial infection
Pt's underlying feelings

22. When performing an ongoing assessment for a patient with disturbed thinking the nurse should be sure to include
Objective
Have them do simple math problems
Level of stress - risk for violence - anxiety level - patient unmet needs
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response

23. The fifth vital sign is
Pain
To ID the problem
Symptoms
ID'ing status of exisiting problems and locating new issues

24. What are the components of a mental status exam that are not part of a regular assessment?
Ongoing assessment
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
School age childen

25. Ageusia is
Toddler
Edema
Serves to expedite dx and tx of actual and potential health problems
Loss of taste

26. The assessment that includes the patient's overhall health status
Pain in legs assoc w walking
Wandering
Paradoxical reaction
Initial assessment

27. At patient that state their shoes are tighter at the end of the day may be experiencing
Pt's with oxygenation and perfusion problems
Pain in legs assoc w walking
No
Edema

28. What is the purpose of the nursing process?
Immature immune system - structures close together lends to easy spreading from on area to another.
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Sensory motor
Serves to expedite dx and tx of actual and potential health problems

29. What are Cheyne Stokes?
Initial assessment
Irregular respirations (fast/slow) often seen at end of life
Double check equip and patient
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.

30. What is the nursing process?
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Tricuspid - mitral and the aortic
A false - fixed belief that cannot be corrected through reasoning.
Interventions for which the nurse is accountable

31. One way to test a person's cognitive ability and abstract thinking ability would be to
Family - spouse - someone other than a healthcare worker - previous medical records.
Wandering
Have them do simple math problems
Pain in legs assoc w walking

32. What would cause changes in congitive development later in life (middle adulthood)?
Trauma or illness
Pain on inspiration and expiration; superficial squeaking or grating
Adolescence
Communicate using hands and eyes.

33. What is pain?
A personal experience that does whatever the person in pain says it does
Double check equip and patient
Pain on inspiration and expiration; superficial squeaking or grating
Assess over all health status and identify the problem

34. The purpose of an intitial assement serves to?
To simulate eating motions with the hands
Assess over all health status and identify the problem
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Decision assessment

35. An example of a secondary source is
Fluid volume deficit related to poor intake
Family - spouse - someone other than a healthcare worker - previous medical records.
Broncial (heard over trachea)
Hemoglobin

36. Another term for a focused assessment is
Ongoing assessment
Adolescence
Communicate using hands and eyes.
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -

37. What is the correct approach when dealing with older adults?
8.4
Pain in legs assoc w walking
# of packs per day x # of years smoked
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response

38. At What age do you begin to use decision making?
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
Communicate using hands and eyes.
Pain on inspiration and expiration; superficial squeaking or grating
Adolescence

39. At What age do you begin to use logical thought process?
Interventions for which the nurse is accountable
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Focused
School age childen

40. When a patient has increased neutrophils - this may indicate what?
Communicate using hands and eyes.
Adolescence
Preschool is cause and effect - school age begins to use logical thought process.
Bacterial infection

41. What does CAM stand for
Sensory motor
Communicate using hands and eyes.
Confusion Assessment Method
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.

42. A nursing dx is best described as
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Capillaries
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
Confusion Assessment Method

43. QUESTT is a tool for What type of an assessment?
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Pain
Initial assessment
Nurse

44. The site where gas exchange occurs is
Double check equip and patient
Pain
Capillaries
School age childen

45. When using restraints in a confused patient
Risk of falls increases
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
The medication will not affect the patient's breathing.
Stroke volume x's heart rate

46. When performing an interview with a patient with vision loss - select the correct questions for obtaining an accurate vision history
Pain on inspiration and expiration; superficial squeaking or grating
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Upper airways
Immature immune system - structures close together lends to easy spreading from on area to another.

47. What are the components of an assessment?
The result is accurate patient dB
Pain on inspiration and expiration; superficial squeaking or grating
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Bacterial infection

48. Describe the purpose of a mental status exam
Defining a baseline of cognitive function - any changes or deviations from norm.
Interventions for which the nurse is accountable
Secondary soureces (family - friends)
Adolescence

49. Nursing interventions should be based on who's theory?
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Maslow
Decreased arterial perfusion
Hearing loss

50. A patient failing to answer questions or displaying a reluctance to participate in group or family activities may be experiencing
Toddler
Hearing loss
Having to use more than one pillow when sleeping
Confusion Assessment Method