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. Acceptable sources of assessment data when evaluating a confused patient would be
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Have them do simple math problems
Ongoing assessment
Secondary soureces (family - friends)


2. The site where gas exchange occurs is
Trauma or illness
Capillaries
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Pt's underlying feelings


3. What are Cheyne Stokes?
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Irregular respirations (fast/slow) often seen at end of life
Pain
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins


4. What are the ABCDE's of pain management?
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
Ask - Believe - Choose - Deliver - Empower
Objective
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -


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

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6. Name the 5 'W's' of assessing a change in LOC
Pain
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Communicate using hands and eyes.
Fluid volume deficit related to poor intake


7. A patient failing to answer questions or displaying a reluctance to participate in group or family activities may be experiencing
Hearing loss
Decreased sense of taste
Having to use more than one pillow when sleeping
Interventions for which the nurse is accountable


8. What does CAM stand for
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Confusion Assessment Method
Ongoing assessment
Communicate using hands and eyes.


9. At What age do you begin to put thoughts into words?
A personal experience that does whatever the person in pain says it does
Toddler
Disorganized thinking and altered LOC
Communicate using hands and eyes.


10. What is the difference between a nursing dx and a med dx?
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital


11. 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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12. A patient that is easily fatigued may have a HgB lab value of?
School age childen
Medical
8.4
Fast and deep respirations seen in patient's with acidosis


13. What is the difference between hallucination and delirium?
Confusion Assessment Method
Decision assessment
Have them do simple math problems
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.


14. What are the steps of the nursing process?
Confusion Assessment Method
Viral infection
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation


15. When speaking with a patient with moderate hearing loss the RN should
Communicate using hands and eyes.
Upper airways
Double check equip and patient
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response


16. Ageusia is
Irregular respirations (fast/slow) often seen at end of life
Loss of taste
Paradoxical reaction
Hearing loss


17. Are changes in vital signs a reliable indicator of chronic pain?
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
No
Risk of falls increases
The process of storing - learning - retrieving - and using info.


18. What is pain?
A personal experience that does whatever the person in pain says it does
Decision assessment
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins


19. What do rhonchi sound like?
ID'ing status of exisiting problems and locating new issues
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Nursing


20. Intermittent claudication is caused by?
Toddler
Decreased arterial perfusion
A false - fixed belief that cannot be corrected through reasoning.
8.4


21. At patient that state their shoes are tighter at the end of the day may be experiencing
Edema
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Medical


22. What is a definition of a delusion?
Snap - crackle - pops; velcro - bubble wrap
A false - fixed belief that cannot be corrected through reasoning.
Ask - Believe - Choose - Deliver - Empower
Focused


23. 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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24. Diabetes is a _________ dx
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Snap - crackle - pops; velcro - bubble wrap
Medical


25. The purpose of an initial assessment is
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
Pain on inspiration and expiration; superficial squeaking or grating
To ID the problem
Inattention and acute increase/decrease in cognitive function


26. What is the cognitive difference between a preschooler and schoolage child?
Hearing loss
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Preschool is cause and effect - school age begins to use logical thought process.
Loss of taste


27. When performing an ongoing assessment for a patient with disturbed thinking the nurse should be sure to include
Pain
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Level of stress - risk for violence - anxiety level - patient unmet needs
Initial assessment


28. When performing an interview with a patient with vision loss - select the correct questions for obtaining an accurate vision history
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Trend assessment (shift report)
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
An 80 y/o patient that has emergency surgery


29. Orthopnea is described as?
Having to use more than one pillow when sleeping
8.4
Confusion Assessment Method
Family - spouse - someone other than a healthcare worker - previous medical records.


30. Which patient would be most likely to experience sensory overload?
Decreased arterial perfusion
8.4
An 80 y/o patient that has emergency surgery
Assess over all health status and identify the problem


31. Sleep deprivation can effect
Upper airways
8.4
Learning - memory and adaptation to stress
Bacterial infection


32. If an abnormal finding is revealed during assessment - the nurse should
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
Decreased arterial perfusion
Double check equip and patient
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)


33. At What age do you begin to use decision making?
No
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
Adolescence
Pain on inspiration and expiration; superficial squeaking or grating


34. What is the formula for cardiac output?

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35. A potential adverse rx of chemically restraining a confused patient would be
Loss of taste
Bacterial infection
Paradoxical reaction
Risk of falls increases


36. The fifth vital sign is
Trauma or illness
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Assess over all health status and identify the problem
Pain


37. Data gathered via instrumention (pulse ox) is considered
Hearing loss
Having to use more than one pillow when sleeping
Decreased sense of taste
Objective


38. What is responsible for transporting O2 in the blood
Secondary soureces (family - friends)
Edema
Having to use more than one pillow when sleeping
Hemoglobin


39. Kussamaul respirations describe

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40. An example of a secondary source is
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
Have them do simple math problems
Knowing What to do/how to make a decision based upon available data.
Family - spouse - someone other than a healthcare worker - previous medical records.


41. Factors that may reduce the efficacy of pulse oximetry include
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
A personal experience that does whatever the person in pain says it does
EdFED- Q
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy


42. What is a chochlear implant?
Hemoglobin
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Family - spouse - someone other than a healthcare worker - previous medical records.
EdFED- Q


43. Why are young children at greater risk for respiratory infection?
Preschool is cause and effect - school age begins to use logical thought process.
Immature immune system - structures close together lends to easy spreading from on area to another.
Risk of falls increases
Decreased arterial perfusion


44. Ongoing assessments are useful in

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45. In Which part of the nursing process will you find delegation?
Implementation
Risk of falls increases
Communicate using hands and eyes.
Ask - Believe - Choose - Deliver - Empower


46. When noticing a patient with dementia has stopped eating - the RN's first response is?
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Maslow
To simulate eating motions with the hands
Non - opiod (ex: NSAID/acetominaphen)


47. All body system data is not necessary which type of assessment
Abstract thinking
Focused
Broncial (heard over trachea)
Maslow


48. Nursing dx provides basis of
Maslow
Interventions for which the nurse is accountable
Defining a baseline of cognitive function - any changes or deviations from norm.
Decreased sense of taste


49. What do rales sound like?
Serves to expedite dx and tx of actual and potential health problems
Snap - crackle - pops; velcro - bubble wrap
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)


50. Inspiration sounds are heard longer than expiration sounds In What area?
An 80 y/o patient that has emergency surgery
Adolescence
Vesicular (peripheral lung areas)
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -