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

2. Describe the purpose of a mental status exam
Defining a baseline of cognitive function - any changes or deviations from norm.
ID'ing status of exisiting problems and locating new issues
Objective
Decision assessment

3. What is the purpose of the nursing process?
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Serves to expedite dx and tx of actual and potential health problems
Surgically implanted device for deaf or hard or hearing - also called bionic ear.

4. Examples of personal information
To ID the problem
Risk of falls increases
Hygeine - DOB - work hx
Sensory motor

5. 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 -
To simulate eating motions with the hands
Knowing What to do/how to make a decision based upon available data.
Data collection - data validation - data organization - data analysis - and data reporting/recording.

6. When performing an ongoing assessment for a patient with disturbed thinking the nurse should be sure to include
Level of stress - risk for violence - anxiety level - patient unmet needs
Defining a baseline of cognitive function - any changes or deviations from norm.
Non - opiod (ex: NSAID/acetominaphen)
A personal experience that does whatever the person in pain says it does

7. What are Piaget's stages of cognitive development
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
Trend assessment (shift report)
Wandering
Adolescence

8. An example of a nursing dx would be
Decreased sense of taste
Fluid volume deficit related to poor intake
Ongoing assessment
Objective

9. Subjective data could include
Trend assessment (shift report)
No
Symptoms
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts

10. If patient reports pain of 3 on scale of 0-10 - What is the appropriate class of pain reliever?
Secondary soureces (family - friends)
Non - opiod (ex: NSAID/acetominaphen)
Defining a baseline of cognitive function - any changes or deviations from norm.
Hearing loss

11. QUESTT is a tool for What type of an assessment?
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Pt's underlying feelings
Snap - crackle - pops; velcro - bubble wrap
Pain

12. What are Cheyne Stokes?
Pain
Hemoglobin
The process of storing - learning - retrieving - and using info.
Irregular respirations (fast/slow) often seen at end of life

13. One way to test a person's cognitive ability and abstract thinking ability would be to
Loss of taste
Have them do simple math problems
Nursing dx
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances

14. What would cause changes in congitive development later in life (middle adulthood)?
Inattention and acute increase/decrease in cognitive function
Daily
Objective
Trauma or illness

15. Acceptable sources of assessment data when evaluating a confused patient would be
Secondary soureces (family - friends)
Having to use more than one pillow when sleeping
Nurse
Immature immune system - structures close together lends to easy spreading from on area to another.

16. Two indicators that are REQUIRED for classification via the CAM tool include
Sensory motor
Non - opiod (ex: NSAID/acetominaphen)
Nursing
Inattention and acute increase/decrease in cognitive function

17. Hypogeusis is
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Hygeine - DOB - work hx
Decreased sense of taste
Symptoms

18. Fluid volume deficit is a __________ dx
Medical
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Viral infection
Nursing

19. A patient failing to answer questions or displaying a reluctance to participate in group or family activities may be experiencing
Fast and deep respirations seen in patient's with acidosis
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
Hearing loss
Sensory motor

20. What is a component of the cognitive part of critical thinking skills?
Vesicular (peripheral lung areas)
An 80 y/o patient that has emergency surgery
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Knowing What to do/how to make a decision based upon available data.

21. When a patient has increased lymphocytes - this may indicate what?
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Viral infection
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
Toddler

22. At patient that state their shoes are tighter at the end of the day may be experiencing
Edema
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
Ask - Believe - Choose - Deliver - Empower

23. When speaking with a patient with moderate hearing loss the RN should
Communicate using hands and eyes.
Adolescence
Decreased sense of taste
Hemoglobin

24. Side effects of putting confused pts in restraints include
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Pain
Communicate using hands and eyes.
A personal experience that does whatever the person in pain says it does

25. If an abnormal finding is revealed during assessment - the nurse should
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Decreased arterial perfusion
Double check equip and patient
Pt's with oxygenation and perfusion problems

26. The purpose of an initial assessment is
Edema
Toddler
Stroke volume x's heart rate
To ID the problem

27. When noticing a patient with dementia has stopped eating - the RN's first response is?
To simulate eating motions with the hands
EdFED- Q
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Serves to expedite dx and tx of actual and potential health problems

28. Data gathered via instrumention (pulse ox) is considered
Family - spouse - someone other than a healthcare worker - previous medical records.
Objective
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Trend assessment (shift report)

29. Another term for a focused assessment is
Sensory motor
Ongoing assessment
Snap - crackle - pops; velcro - bubble wrap
Family - spouse - someone other than a healthcare worker - previous medical records.

30. What are the components of an assessment?
Inattention and acute increase/decrease in cognitive function
Data collection - data validation - data organization - data analysis - and data reporting/recording.
8.4
A false - fixed belief that cannot be corrected through reasoning.

31. What is a definition of a delusion?
Toddler
The patient
A false - fixed belief that cannot be corrected through reasoning.
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy

32. In Which part of the nursing process will you find delegation?
Implementation
Confusion Assessment Method
EdFED- Q
Fast and deep respirations seen in patient's with acidosis

33. Orthopnea is described as?
Knowing What to do/how to make a decision based upon available data.
Having to use more than one pillow when sleeping
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Symptoms

34. At What age do you begin to put thoughts into words?
Toddler
Assess over all health status and identify the problem
Upper airways
Pain on inspiration and expiration; superficial squeaking or grating

35. Expiration sounds are heard longer than inspiration In What area?
Broncial (heard over trachea)
Communicate using hands and eyes.
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Nursing

36. Inspiration sounds are heard longer than expiration sounds In What area?
Vesicular (peripheral lung areas)
Pain on inspiration and expiration; superficial squeaking or grating
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy

37. 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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38. What is pain?
A personal experience that does whatever the person in pain says it does
Secondary soureces (family - friends)
Decreased sense of taste
Nursing

39. Data from the last 24/48 hours that included patterns would be a part of
Upper airways
Immature immune system - structures close together lends to easy spreading from on area to another.
Trend assessment (shift report)
Broncial (heard over trachea)

40. Ageusia is
Fast and deep respirations seen in patient's with acidosis
Pt's with oxygenation and perfusion problems
Have them do simple math problems
Loss of taste

41. What is the formula for determining pack years?
Sensory motor
Preschool is cause and effect - school age begins to use logical thought process.
The process of storing - learning - retrieving - and using info.
# of packs per day x # of years smoked

42. Blood passes through the heart valves In what order?
Inattention and acute increase/decrease in cognitive function
Fluid volume deficit related to poor intake
Tricuspid - mitral and the aortic
Immature immune system - structures close together lends to easy spreading from on area to another.

43. A nursing dx is best described as
Secondary
Viral infection
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
Hemoglobin

44. When performing an interview with a patient with vision loss - select the correct questions for obtaining an accurate vision history
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
Bacterial infection
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.

45. When using restraints in a confused patient
Risk of falls increases
Pain in legs assoc w walking
Viral infection
Snap - crackle - pops; velcro - bubble wrap

46. What is the difference between a nursing dx and a med dx?
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Snap - crackle - pops; velcro - bubble wrap
Knowing What to do/how to make a decision based upon available data.
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital

47. Other factors that may indicate confusion using the CAM tool could be
Disorganized thinking and altered LOC
Ask - Believe - Choose - Deliver - Empower
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
8.4

48. The assessment that includes the patient's overhall health status
Initial assessment
EdFED- Q
Fluid volume deficit related to poor intake
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)

49. At What age do you begin to use logical thought process?
Vesicular (peripheral lung areas)
Daily
School age childen
Adolescence

50. Would a nursing dx be part of the primary or secondary dx?
Edema
Secondary
Decreased sense of taste
Non - opiod (ex: NSAID/acetominaphen)