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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. Blood passes through the heart valves In what order?
Have them do simple math problems
Decision assessment
Tricuspid - mitral and the aortic
Fast and deep respirations seen in patient's with acidosis

2. What do rhonchi sound like?
Loss of taste
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
The patient
The medication will not affect the patient's breathing.

3. QUESTT is a tool for What type of an assessment?
Trend assessment (shift report)
Risk of falls increases
Pain
Have them do simple math problems

4. What are the steps of the nursing process?
An 80 y/o patient that has emergency surgery
Immature immune system - structures close together lends to easy spreading from on area to another.
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Confusion Assessment Method

5. In Which part of the nursing process will you find delegation?
Implementation
Ask - Believe - Choose - Deliver - Empower
Viral infection
Hemoglobin

6. What would cause changes in congitive development later in life (middle adulthood)?
Family - spouse - someone other than a healthcare worker - previous medical records.
Trauma or illness
Immature immune system - structures close together lends to easy spreading from on area to another.
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)

7. What are Piaget's stages of cognitive development
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Confusion Assessment Method
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
Upper airways

8. When noticing a patient with dementia has stopped eating - the RN's first response is?
Learning - memory and adaptation to stress
Knowing What to do/how to make a decision based upon available data.
Daily
To simulate eating motions with the hands

9. Data from the last 24/48 hours that included patterns would be a part of
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Trend assessment (shift report)
Fluid volume deficit related to poor intake

10. At patient that state their shoes are tighter at the end of the day may be experiencing
Trauma or illness
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Edema
Assess over all health status and identify the problem

11. An example of a nursing dx would be
Fluid volume deficit related to poor intake
Abstract thinking
Irregular respirations (fast/slow) often seen at end of life
Decision assessment

12. The order of air flow into the lungs is
Implementation
Communicate using hands and eyes.
Defining a baseline of cognitive function - any changes or deviations from norm.
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli

13. Describe the purpose of a mental status exam
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
Pain on inspiration and expiration; superficial squeaking or grating
Defining a baseline of cognitive function - any changes or deviations from norm.
Family - spouse - someone other than a healthcare worker - previous medical records.

14. Factors that may reduce the efficacy of pulse oximetry include
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
A false - fixed belief that cannot be corrected through reasoning.
Have them do simple math problems
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -

15. Inspiration sounds are heard longer than expiration sounds In What area?
Decision assessment
Vesicular (peripheral lung areas)
Ongoing assessment
School age childen

16. What is the difference between a nursing dx and a med dx?
Stroke volume x's heart rate
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Ask - Believe - Choose - Deliver - Empower
Knowing What to do/how to make a decision based upon available data.

17. At What age do you begin to use decision making?
Adolescence
Preschool is cause and effect - school age begins to use logical thought process.
Pt's underlying feelings
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.

18. 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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19. When using restraints in a confused patient
Upper airways
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Risk of falls increases
Fluid volume deficit related to poor intake

20. Once a medical dx has been made - who is accountable for the reporting s/s of complications?
Preschool is cause and effect - school age begins to use logical thought process.
Focused
Nurse
Nursing

21. What is a component of the cognitive part of critical thinking skills?
Communicate using hands and eyes.
Adolescence
Loss of taste
Knowing What to do/how to make a decision based upon available data.

22. What is the formula for cardiac output?

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23. An example of a secondary source is
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Snap - crackle - pops; velcro - bubble wrap
Pt's underlying feelings
Family - spouse - someone other than a healthcare worker - previous medical records.

24. A nursing dx is best described as
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Non - opiod (ex: NSAID/acetominaphen)
Level of stress - risk for violence - anxiety level - patient unmet needs

25. What is the formula for determining pack years?
Immature immune system - structures close together lends to easy spreading from on area to another.
# of packs per day x # of years smoked
Risk of falls increases
Surgically implanted device for deaf or hard or hearing - also called bionic ear.

26. What is a chochlear implant?
Family - spouse - someone other than a healthcare worker - previous medical records.
Daily
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Decreased sense of taste

27. What scale is used to determine eating and feeding issues in adults with confusion
EdFED- Q
The result is accurate patient dB
Adolescence
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.

28. What is a definition of a delusion?
Maslow
Medical
Pain in legs assoc w walking
A false - fixed belief that cannot be corrected through reasoning.

29. What factors may indicate plural rub?
# of packs per day x # of years smoked
Pain on inspiration and expiration; superficial squeaking or grating
Capillaries
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances

30. Why are young children at greater risk for respiratory infection?
Symptoms
Medical
School age childen
Immature immune system - structures close together lends to easy spreading from on area to another.

31. What are the components of an assessment?
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Trend assessment (shift report)
To simulate eating motions with the hands
Pain on inspiration and expiration; superficial squeaking or grating

32. The path of blood from the lungs to the heart is
Broncial (heard over trachea)
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Edema
Implementation

33. The basis for a plan of care comes for which stage of the nursing process?
The medication will not affect the patient's breathing.
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Nursing dx

34. One way to test a person's cognitive ability and abstract thinking ability would be to
Have them do simple math problems
Toddler
Family - spouse - someone other than a healthcare worker - previous medical records.
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy

35. What is pain?
Implementation
ID'ing status of exisiting problems and locating new issues
Double check equip and patient
A personal experience that does whatever the person in pain says it does

36. What is responsible for transporting O2 in the blood
Serves to expedite dx and tx of actual and potential health problems
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Hemoglobin
Family - spouse - someone other than a healthcare worker - previous medical records.

37. Ageusia is
Knowing What to do/how to make a decision based upon available data.
Loss of taste
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
An 80 y/o patient that has emergency surgery

38. Expiration sounds are heard longer than inspiration In What area?
A false - fixed belief that cannot be corrected through reasoning.
Preschool is cause and effect - school age begins to use logical thought process.
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Broncial (heard over trachea)

39. 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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40. When speaking with a patient with moderate hearing loss the RN should
Ongoing assessment
Communicate using hands and eyes.
Viral infection
Adolescence

41. Are changes in vital signs a reliable indicator of chronic pain?
Defining a baseline of cognitive function - any changes or deviations from norm.
Secondary
No
Knowing What to do/how to make a decision based upon available data.

42. What is the cognitive difference between a preschooler and schoolage child?
Preschool is cause and effect - school age begins to use logical thought process.
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
An 80 y/o patient that has emergency surgery
The process of storing - learning - retrieving - and using info.

43. All body system data is not necessary which type of assessment
Adolescence
Symptoms
Decreased sense of taste
Focused

44. Subjective data could include
Data collection - data validation - data organization - data analysis - and data reporting/recording.
To ID the problem
The result is accurate patient dB
Symptoms

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

46. The path of blood from the heart to the lungs is
Communicate using hands and eyes.
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
EdFED- Q

47. The purpose of an initial assessment is
Objective
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
To ID the problem
Risk of falls increases

48. 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
Trend assessment (shift report)
Decreased arterial perfusion
Stroke volume x's heart rate

49. Side effects of putting confused pts in restraints include
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Knowing What to do/how to make a decision based upon available data.
# of packs per day x # of years smoked
Loss of taste

50. 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
Defining a baseline of cognitive function - any changes or deviations from norm.
Data collection - data validation - data organization - data analysis - and data reporting/recording.

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Nursing Fundamentals 3

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