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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. What are Piaget's stages of cognitive development
School age childen
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
Family - spouse - someone other than a healthcare worker - previous medical records.
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances

2. QUESTT is a tool for What type of an assessment?
Pain
Capillaries
Nurse
Trauma or illness

3. What is cognition?
The process of storing - learning - retrieving - and using info.
Upper airways
Nursing
Level of stress - risk for violence - anxiety level - patient unmet needs

4. What is a component of the cognitive part of critical thinking skills?
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
No
# of packs per day x # of years smoked
Knowing What to do/how to make a decision based upon available data.

5. What is intermittent claudication?
Trauma or illness
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Pain in legs assoc w walking
Double check equip and patient

6. Once a medical dx has been made - who is accountable for the reporting s/s of complications?
Fast and deep respirations seen in patient's with acidosis
Stroke volume x's heart rate
Ask - Believe - Choose - Deliver - Empower
Nurse

7. Types of hearing loss include
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Maslow
Preschool is cause and effect - school age begins to use logical thought process.
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)

8. Why are young children at greater risk for respiratory infection?
Sensory motor
Paradoxical reaction
Edema
Immature immune system - structures close together lends to easy spreading from on area to another.

9. 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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10. What are the components of an assessment?
Hearing loss
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Hemoglobin
Data collection - data validation - data organization - data analysis - and data reporting/recording.

11. Data that is recorded for an immediate need (code blue or fall) would be included in
Pain
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Decision assessment
To simulate eating motions with the hands

12. What is the correct approach when dealing with older adults?
Upper airways
The process of storing - learning - retrieving - and using info.
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response

13. A patient failing to answer questions or displaying a reluctance to participate in group or family activities may be experiencing
Hearing loss
Knowing What to do/how to make a decision based upon available data.
Maslow
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital

14. Are changes in vital signs a reliable indicator of chronic pain?
Pain
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
No
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli

15. Where can you hear bronchovesicular breath sounds?
Assess over all health status and identify the problem
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Hearing loss
Pain on inspiration and expiration; superficial squeaking or grating

16. The assessment that includes the patient's overhall health status
Pt's with oxygenation and perfusion problems
Pt's underlying feelings
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Initial assessment

17. What are the ABCDE's of pain management?
Risk of falls increases
EdFED- Q
Ask - Believe - Choose - Deliver - Empower
Assess over all health status and identify the problem

18. What are Cheyne Stokes?
Assess over all health status and identify the problem
Irregular respirations (fast/slow) often seen at end of life
School age childen
Inattention and acute increase/decrease in cognitive function

19. What is the purpose of the nursing process?
Serves to expedite dx and tx of actual and potential health problems
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
# of packs per day x # of years smoked
A personal experience that does whatever the person in pain says it does

20. In Which part of the nursing process will you find delegation?
Decision assessment
8.4
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Implementation

21. What is the formula for determining pack years?
# of packs per day x # of years smoked
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Pain
Snap - crackle - pops; velcro - bubble wrap

22. The path of blood from the heart to the lungs is
Fluid volume deficit related to poor intake
Secondary
An 80 y/o patient that has emergency surgery
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins

23. An example of a secondary source is
Inattention and acute increase/decrease in cognitive function
Family - spouse - someone other than a healthcare worker - previous medical records.
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Pt's with oxygenation and perfusion problems

24. Expiration sounds are heard longer than inspiration In What area?
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Symptoms
Broncial (heard over trachea)

25. Describe the purpose of a mental status exam
Vesicular (peripheral lung areas)
Inattention and acute increase/decrease in cognitive function
Defining a baseline of cognitive function - any changes or deviations from norm.
Maslow

26. What does CAM stand for
Immature immune system - structures close together lends to easy spreading from on area to another.
Confusion Assessment Method
Hygeine - DOB - work hx
Implementation

27. All body system data is not necessary which type of assessment
Focused
School age childen
Defining a baseline of cognitive function - any changes or deviations from norm.
Capillaries

28. An example of a primary source is
The patient
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Disorganized thinking and altered LOC
Defining a baseline of cognitive function - any changes or deviations from norm.

29. A potential adverse rx of chemically restraining a confused patient would be
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Decision assessment
Secondary soureces (family - friends)
Paradoxical reaction

30. At What age do you begin to use logical thought process?
School age childen
Hearing loss
Trauma or illness
Pt's with oxygenation and perfusion problems

31. 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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32. What is the nursing process?
Confusion Assessment Method
Interventions for which the nurse is accountable
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Objective

33. At What age do you begin to use decision making?
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Adolescence
Trend assessment (shift report)
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.

34. Acceptable sources of assessment data when evaluating a confused patient would be
Nursing
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Non - opiod (ex: NSAID/acetominaphen)
Secondary soureces (family - friends)

35. One way to test a person's cognitive ability and abstract thinking ability would be to
Broncial (heard over trachea)
8.4
Hearing loss
Have them do simple math problems

36. Other factors that may indicate confusion using the CAM tool could be
Pt's with oxygenation and perfusion problems
Disorganized thinking and altered LOC
EdFED- Q
Symptoms

37. Kussamaul respirations describe

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38. When noticing a patient with dementia has stopped eating - the RN's first response is?
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Ongoing assessment
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
To simulate eating motions with the hands

39. Where can wheezes best be heard?
Interventions for which the nurse is accountable
Ongoing assessment
Upper airways
Preschool is cause and effect - school age begins to use logical thought process.

40. When performing an interview with a patient with vision loss - select the correct questions for obtaining an accurate vision history
Level of stress - risk for violence - anxiety level - patient unmet needs
Interventions for which the nurse is accountable
Symptoms
Eye hygeine - accomodating factors - what was the level of decline - how long has it been

41. An infant is in which Paiget stage?
Pain
Tricuspid - mitral and the aortic
Medical
Sensory motor

42. Subjective data could include
ID'ing status of exisiting problems and locating new issues
Non - opiod (ex: NSAID/acetominaphen)
Symptoms
Data collection - data validation - data organization - data analysis - and data reporting/recording.

43. Data from the last 24/48 hours that included patterns would be a part of
Trauma or illness
Adolescence
Trend assessment (shift report)
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)

44. Ongoing assessments are useful in

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45. Intermittent claudication is caused by?
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Decreased arterial perfusion
Abstract thinking

46. Nursing interventions should be based on who's theory?
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Maslow
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital

47. Orthopnea is described as?
Have them do simple math problems
Hemoglobin
Sensory motor
Having to use more than one pillow when sleeping

48. The path of blood from the lungs to the heart is
Level of stress - risk for violence - anxiety level - patient unmet needs
Adolescence
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
No

49. Side effects of putting confused pts in restraints include
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
An 80 y/o patient that has emergency surgery
Maslow
Have them do simple math problems

50. The purpose of an intitial assement serves to?
Assess over all health status and identify the problem
Immature immune system - structures close together lends to easy spreading from on area to another.
Nursing dx
# of packs per day x # of years smoked