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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. Why are young children at greater risk for respiratory infection?
Immature immune system - structures close together lends to easy spreading from on area to another.
Double check equip and patient
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
The patient

2. The path of blood from the heart to the lungs is
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Sensory motor
Decreased arterial perfusion
Having to use more than one pillow when sleeping

3. When performing an interview with a patient with vision loss - select the correct questions for obtaining an accurate vision history
Vesicular (peripheral lung areas)
Focused
Nursing dx
Eye hygeine - accomodating factors - what was the level of decline - how long has it been

4. When performing an ongoing assessment for a patient with disturbed thinking the nurse should be sure to include
Confusion Assessment Method
Assess over all health status and identify the problem
The medication will not affect the patient's breathing.
Level of stress - risk for violence - anxiety level - patient unmet needs

5. A patient that is easily fatigued may have a HgB lab value of?
8.4
Preschool is cause and effect - school age begins to use logical thought process.
Focused
A false - fixed belief that cannot be corrected through reasoning.

6. If patient reports pain of 3 on scale of 0-10 - What is the appropriate class of pain reliever?
Ongoing assessment
Pain in legs assoc w walking
Non - opiod (ex: NSAID/acetominaphen)
Learning - memory and adaptation to stress

7. Side effects of putting confused pts in restraints include
EdFED- Q
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
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

8. Are changes in vital signs a reliable indicator of chronic pain?
No
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Toddler

9. A potential adverse rx of chemically restraining a confused patient would be
Paradoxical reaction
Decreased arterial perfusion
Ongoing assessment
Loss of taste

10. A patient that is dying is on morphine. The family is concerned the prs breathing will stop. What is the correct RN response?

11. What does CAM stand for
Confusion Assessment Method
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
To simulate eating motions with the hands
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve

12. A patient failing to answer questions or displaying a reluctance to participate in group or family activities may be experiencing
Hearing loss
Pt's underlying feelings
Fast and deep respirations seen in patient's with acidosis
Inattention and acute increase/decrease in cognitive function

13. Data validation assures
The result is accurate patient dB
Ongoing assessment
Preschool is cause and effect - school age begins to use logical thought process.
Implementation

14. Where can you hear bronchovesicular breath sounds?
Assess over all health status and identify the problem
Irregular respirations (fast/slow) often seen at end of life
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Confusion Assessment Method

15. What are the components of an assessment?
Ongoing assessment
An 80 y/o patient that has emergency surgery
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Learning - memory and adaptation to stress

16. What are Cheyne Stokes?
The patient
Level of stress - risk for violence - anxiety level - patient unmet needs
Irregular respirations (fast/slow) often seen at end of life
Nurse

17. One way to test a person's cognitive ability and abstract thinking ability would be to
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
Have them do simple math problems
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital

18. Subjective data could include
Secondary soureces (family - friends)
Broncial (heard over trachea)
Symptoms
Nurse

19. The basis for a plan of care comes for which stage of the nursing process?
Trend assessment (shift report)
Nursing dx
Daily
Maslow

20. Keeping patient's belongings - shoes - suitcases and street clothes - etc. out of view are helpful for preventing: wandering?
Pain
Wandering
Hemoglobin
Fast and deep respirations seen in patient's with acidosis

21. At What age do you begin to put thoughts into words?
Pain on inspiration and expiration; superficial squeaking or grating
Tricuspid - mitral and the aortic
Immature immune system - structures close together lends to easy spreading from on area to another.
Toddler

22. What would cause changes in congitive development later in life (middle adulthood)?
Trauma or illness
# of packs per day x # of years smoked
To simulate eating motions with the hands
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.

23. The purpose of an initial assessment is
Loss of taste
Focused
To ID the problem
Preschool is cause and effect - school age begins to use logical thought process.

24. What do rhonchi sound like?
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Maslow
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts

25. Blood passes through the heart valves In what order?
Snap - crackle - pops; velcro - bubble wrap
Tricuspid - mitral and the aortic
Risk of falls increases
Ongoing assessment

26. The path of blood from the lungs to the heart is
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Trend assessment (shift report)
Maslow
Fast and deep respirations seen in patient's with acidosis

27. When noticing a patient with dementia has stopped eating - the RN's first response is?
8.4
Nurse
Upper airways
To simulate eating motions with the hands

28. What is pain?
A personal experience that does whatever the person in pain says it does
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Immature immune system - structures close together lends to easy spreading from on area to another.
Assess over all health status and identify the problem

29. Types of hearing loss include
Defining a baseline of cognitive function - any changes or deviations from norm.
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
Tricuspid - mitral and the aortic
# of packs per day x # of years smoked

30. If an abnormal finding is revealed during assessment - the nurse should
Paradoxical reaction
Immature immune system - structures close together lends to easy spreading from on area to another.
Double check equip and patient
Focused

31. What are the components of a mental status exam that are not part of a regular assessment?
Trauma or illness
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
To simulate eating motions with the hands
Risk of falls increases

32. Which patient would be most likely to experience sensory overload?
Loss of taste
Stroke volume x's heart rate
An 80 y/o patient that has emergency surgery
A false - fixed belief that cannot be corrected through reasoning.

33. Intermittent claudication is caused by?
Trauma or illness
Decreased arterial perfusion
Nursing dx
Pain in legs assoc w walking

34. When using restraints in a confused patient
Disorganized thinking and altered LOC
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Risk of falls increases
Edema

35. At What age do you begin to use logical thought process?
School age childen
Family - spouse - someone other than a healthcare worker - previous medical records.
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Serves to expedite dx and tx of actual and potential health problems

36. An example of a primary source is
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
A false - fixed belief that cannot be corrected through reasoning.
Level of stress - risk for violence - anxiety level - patient unmet needs
The patient

37. What is the cognitive difference between a preschooler and schoolage child?
Inattention and acute increase/decrease in cognitive function
Maslow
Non - opiod (ex: NSAID/acetominaphen)
Preschool is cause and effect - school age begins to use logical thought process.

38. Data gathered via instrumention (pulse ox) is considered
Immature immune system - structures close together lends to easy spreading from on area to another.
Objective
Pt's underlying feelings
A personal experience that does whatever the person in pain says it does

39. At patient that state their shoes are tighter at the end of the day may be experiencing
Trend assessment (shift report)
Symptoms
Edema
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.

40. An infant is in which Paiget stage?
Objective
Daily
Sensory motor
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli

41. An ongoing assessment is performed
Secondary soureces (family - friends)
Paradoxical reaction
Stroke volume x's heart rate
Daily

42. Another term for a focused assessment is
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Nursing
Sensory motor
Ongoing assessment

43. What are the ABCDE's of pain management?
Ask - Believe - Choose - Deliver - Empower
Inattention and acute increase/decrease in cognitive function
Toddler
Initial assessment

44. Orthopnea is described as?
Medical
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
Having to use more than one pillow when sleeping
Disorganized thinking and altered LOC

45. Name the 5 'W's' of assessing a change in LOC
Confusion Assessment Method
Abstract thinking
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.

46. Nursing interventions should be based on who's theory?
The result is accurate patient dB
Maslow
Sensory motor
Paradoxical reaction

47. Would a nursing dx be part of the primary or secondary dx?
Trauma or illness
Secondary
Pt's with oxygenation and perfusion problems
The medication will not affect the patient's breathing.

48. The assessment that includes the patient's overhall health status
Pain in legs assoc w walking
Double check equip and patient
Implementation
Initial assessment

49. What is intermittent claudication?
Pain in legs assoc w walking
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Learning - memory and adaptation to stress

50. What is the correct approach when dealing with older adults?
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
The process of storing - learning - retrieving - and using info.
Defining a baseline of cognitive function - any changes or deviations from norm.
Stroke volume x's heart rate