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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. Would a nursing dx be part of the primary or secondary dx?
Secondary
Nursing dx
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Serves to expedite dx and tx of actual and potential health problems

2. If patient reports pain of 3 on scale of 0-10 - What is the appropriate class of pain reliever?
Having to use more than one pillow when sleeping
# of packs per day x # of years smoked
Objective
Non - opiod (ex: NSAID/acetominaphen)

3. At What age do you begin to use logical thought process?
Assess over all health status and identify the problem
Trend assessment (shift report)
School age childen
Double check equip and patient

4. Acceptable sources of assessment data when evaluating a confused patient would be
Secondary soureces (family - friends)
Adolescence
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Decision assessment

5. All body system data is not necessary which type of assessment
Paradoxical reaction
Immature immune system - structures close together lends to easy spreading from on area to another.
Focused
Hemoglobin

6. The assessment that includes the patient's overhall health status
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
Initial assessment
Pain on inspiration and expiration; superficial squeaking or grating
The medication will not affect the patient's breathing.

7. Asking a patient what would you do if there is a fire in the wastebasket - is a way to assess their
No
Risk of falls increases
Abstract thinking
The medication will not affect the patient's breathing.

8. What is a component of the cognitive part of critical thinking skills?
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
Secondary
Knowing What to do/how to make a decision based upon available data.

9. The purpose of an initial assessment is
Pt's underlying feelings
To ID the problem
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Abstract thinking

10. Two indicators that are REQUIRED for classification via the CAM tool include
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Pain
Decreased arterial perfusion
Inattention and acute increase/decrease in cognitive function

11. The path of blood from the heart to the lungs is
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
The result is accurate patient dB
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Have them do simple math problems

12. What is responsible for transporting O2 in the blood
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
Pain on inspiration and expiration; superficial squeaking or grating
Hemoglobin
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins

13. Nursing interventions should be based on who's theory?
Pain in legs assoc w walking
Maslow
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
The result is accurate patient dB

14. Ageusia is
Loss of taste
Confusion Assessment Method
Paradoxical reaction
Hearing loss

15. What is the difference between hallucination and delirium?
Medical
Non - opiod (ex: NSAID/acetominaphen)
Fast and deep respirations seen in patient's with acidosis
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.

16. An example of a nursing dx would be
Nurse
Fluid volume deficit related to poor intake
Loss of taste
Surgically implanted device for deaf or hard or hearing - also called bionic ear.

17. Expiration sounds are heard longer than inspiration In What area?
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Broncial (heard over trachea)
Decreased sense of taste
Double check equip and patient

18. What do rales sound like?
Sensory motor
Bacterial infection
Snap - crackle - pops; velcro - bubble wrap
Hearing loss

19. Where can wheezes best be heard?
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Upper airways
# of packs per day x # of years smoked
Trauma or illness

20. A potential adverse rx of chemically restraining a confused patient would be
Paradoxical reaction
Maslow
Wandering
Decision assessment

21. Orthopnea is described as?
Pain
Having to use more than one pillow when sleeping
Confusion Assessment Method
The process of storing - learning - retrieving - and using info.

22. Examples of personal information
To ID the problem
Hygeine - DOB - work hx
ID'ing status of exisiting problems and locating new issues
Double check equip and patient

23. An ongoing assessment is performed
Implementation
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Daily
Nursing

24. Kussamaul respirations describe

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25. What are Piaget's stages of cognitive development
Interventions for which the nurse is accountable
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
Maslow
Ask - Believe - Choose - Deliver - Empower

26. Another term for a focused assessment is
Pain in legs assoc w walking
Ongoing assessment
Nurse
Bacterial infection

27. Other factors that may indicate confusion using the CAM tool could be
Fluid volume deficit related to poor intake
Implementation
Disorganized thinking and altered LOC
An 80 y/o patient that has emergency surgery

28. What is pain?
A personal experience that does whatever the person in pain says it does
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
Risk of falls increases
Defining a baseline of cognitive function - any changes or deviations from norm.

29. What is the cognitive difference between a preschooler and schoolage child?
School age childen
Preschool is cause and effect - school age begins to use logical thought process.
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Secondary

30. What do rhonchi sound like?
Viral infection
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Having to use more than one pillow when sleeping

31. A patient that is easily fatigued may have a HgB lab value of?
EdFED- Q
Decreased sense of taste
8.4
Decreased arterial perfusion

32. What are the components of an assessment?
Decreased arterial perfusion
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Risk of falls increases
Non - opiod (ex: NSAID/acetominaphen)

33. What is the correct approach when dealing with older adults?
Level of stress - risk for violence - anxiety level - patient unmet needs
EdFED- Q
Knowing What to do/how to make a decision based upon available data.
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response

34. Intermittent claudication is caused by?
Level of stress - risk for violence - anxiety level - patient unmet needs
Ongoing assessment
Confusion Assessment Method
Decreased arterial perfusion

35. Name the 5 'W's' of assessing a change in LOC
Symptoms
Ongoing assessment
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Hemoglobin

36. What would cause changes in congitive development later in life (middle adulthood)?
Defining a baseline of cognitive function - any changes or deviations from norm.
Trauma or illness
School age childen
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation

37. Once a medical dx has been made - who is accountable for the reporting s/s of complications?
Medical
Nurse
Assess over all health status and identify the problem
Irregular respirations (fast/slow) often seen at end of life

38. When noticing a patient with dementia has stopped eating - the RN's first response is?
Ongoing assessment
The process of storing - learning - retrieving - and using info.
Nursing dx
To simulate eating motions with the hands

39. Diabetes is a _________ dx
Adolescence
Medical
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Interventions for which the nurse is accountable

40. The basis for a plan of care comes for which stage of the nursing process?
Nursing dx
The medication will not affect the patient's breathing.
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
Pain in legs assoc w walking

41. What is the difference between a nursing dx and a med dx?
Nursing dx
# of packs per day x # of years smoked
Decreased sense of taste
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital

42. Blood passes through the heart valves In what order?
Tricuspid - mitral and the aortic
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Decreased arterial perfusion
Vesicular (peripheral lung areas)

43. QUESTT is a tool for What type of an assessment?
Pain
Preschool is cause and effect - school age begins to use logical thought process.
Pain in legs assoc w walking
8.4

44. At What age do you begin to put thoughts into words?
Secondary
Toddler
Nursing
Level of stress - risk for violence - anxiety level - patient unmet needs

45. What is a definition of a delusion?
A false - fixed belief that cannot be corrected through reasoning.
Immature immune system - structures close together lends to easy spreading from on area to another.
Preschool is cause and effect - school age begins to use logical thought process.
# of packs per day x # of years smoked

46. What is a chochlear implant?
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Inattention and acute increase/decrease in cognitive function
Irregular respirations (fast/slow) often seen at end of life
Level of stress - risk for violence - anxiety level - patient unmet needs

47. Why are young children at greater risk for respiratory infection?
Fast and deep respirations seen in patient's with acidosis
Tricuspid - mitral and the aortic
Implementation
Immature immune system - structures close together lends to easy spreading from on area to another.

48. In Which part of the nursing process will you find delegation?
Focused
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Implementation
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.

49. What are the steps of the nursing process?
Nursing
# of packs per day x # of years smoked
Fast and deep respirations seen in patient's with acidosis
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation

50. Data from the last 24/48 hours that included patterns would be a part of
Pain on inspiration and expiration; superficial squeaking or grating
Implementation
Trend assessment (shift report)
School age childen