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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. Side effects of putting confused pts in restraints include
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Ask - Believe - Choose - Deliver - Empower

2. At What age do you begin to use decision making?
Implementation
School age childen
Ask - Believe - Choose - Deliver - Empower
Adolescence

3. ABG's would be an important lab value for What types of patient's?

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4. When a patient has increased neutrophils - this may indicate what?
Vesicular (peripheral lung areas)
Bacterial infection
Secondary soureces (family - friends)
School age childen

5. Why are young children at greater risk for respiratory infection?
Secondary
Immature immune system - structures close together lends to easy spreading from on area to another.
Assess over all health status and identify the problem
Bacterial infection

6. Which patient would be most likely to experience sensory overload?
Assess over all health status and identify the problem
An 80 y/o patient that has emergency surgery
The result is accurate patient dB
Trend assessment (shift report)

7. The order of air flow into the lungs is
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
An 80 y/o patient that has emergency surgery
Hygeine - DOB - work hx
Abstract thinking

8. Examples of personal information
Disorganized thinking and altered LOC
Serves to expedite dx and tx of actual and potential health problems
Initial assessment
Hygeine - DOB - work hx

9. One way to test a person's cognitive ability and abstract thinking ability would be to
Bacterial infection
Sensory motor
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Have them do simple math problems

10. Describe the purpose of a mental status exam
Defining a baseline of cognitive function - any changes or deviations from norm.
Inattention and acute increase/decrease in cognitive function
Ask - Believe - Choose - Deliver - Empower
Surgically implanted device for deaf or hard or hearing - also called bionic ear.

11. What would cause changes in congitive development later in life (middle adulthood)?
Irregular respirations (fast/slow) often seen at end of life
Defining a baseline of cognitive function - any changes or deviations from norm.
Trauma or illness
Bacterial infection

12. Subjective data could include
Upper airways
Immature immune system - structures close together lends to easy spreading from on area to another.
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Symptoms

13. At What age do you begin to use logical thought process?
Have them do simple math problems
School age childen
Wandering
Loss of taste

14. What is responsible for transporting O2 in the blood
Implementation
Pain
Hemoglobin
Non - opiod (ex: NSAID/acetominaphen)

15. What are the components of a mental status exam that are not part of a regular assessment?
Stroke volume x's heart rate
Hygeine - DOB - work hx
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
Having to use more than one pillow when sleeping

16. Ongoing assessments are useful in

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17. When a patient has increased lymphocytes - this may indicate what?
Viral infection
# of packs per day x # of years smoked
The patient
Hearing loss

18. Another term for a focused assessment is
Daily
Nurse
Ongoing assessment
Abstract thinking

19. If an abnormal finding is revealed during assessment - the nurse should
Double check equip and patient
Defining a baseline of cognitive function - any changes or deviations from norm.
Pain
No

20. Are changes in vital signs a reliable indicator of chronic pain?
To ID the problem
Fast and deep respirations seen in patient's with acidosis
No
Inattention and acute increase/decrease in cognitive function

21. What scale is used to determine eating and feeding issues in adults with confusion
Nursing
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Pt's with oxygenation and perfusion problems
EdFED- Q

22. The fifth vital sign is
Symptoms
School age childen
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
Pain

23. Data gathered via instrumention (pulse ox) is considered
Loss of taste
A personal experience that does whatever the person in pain says it does
Fluid volume deficit related to poor intake
Objective

24. QUESTT is a tool for What type of an assessment?
Snap - crackle - pops; velcro - bubble wrap
Capillaries
Pain on inspiration and expiration; superficial squeaking or grating
Pain

25. What is the nursing process?
Defining a baseline of cognitive function - any changes or deviations from norm.
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Symptoms
Eye hygeine - accomodating factors - what was the level of decline - how long has it been

26. Asking a patient what would you do if there is a fire in the wastebasket - is a way to assess their
Hemoglobin
Pain on inspiration and expiration; superficial squeaking or grating
Have them do simple math problems
Abstract thinking

27. 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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28. A patient that is easily fatigued may have a HgB lab value of?
8.4
School age childen
Abstract thinking
Nursing

29. The purpose of an intitial assement serves to?
Assess over all health status and identify the problem
Wandering
A false - fixed belief that cannot be corrected through reasoning.
To simulate eating motions with the hands

30. Intermittent claudication is caused by?
Decreased arterial perfusion
ID'ing status of exisiting problems and locating new issues
Pain in legs assoc w walking
Confusion Assessment Method

31. An infant is in which Paiget stage?
Ongoing assessment
Sensory motor
Wandering
Daily

32. Data validation assures
Trauma or illness
Pain in legs assoc w walking
The result is accurate patient dB
Disorganized thinking and altered LOC

33. Ageusia is
Assess over all health status and identify the problem
Snap - crackle - pops; velcro - bubble wrap
Maslow
Loss of taste

34. When performing an interview with a patient with vision loss - select the correct questions for obtaining an accurate vision history
The process of storing - learning - retrieving - and using info.
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.
Upper airways

35. A patient failing to answer questions or displaying a reluctance to participate in group or family activities may be experiencing
The medication will not affect the patient's breathing.
Decreased arterial perfusion
Hearing loss
EdFED- Q

36. Fluid volume deficit is a __________ dx
The process of storing - learning - retrieving - and using info.
Nursing
Edema
Sensory motor

37. What is a component of the cognitive part of critical thinking skills?
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Edema
Vesicular (peripheral lung areas)
Knowing What to do/how to make a decision based upon available data.

38. Would a nursing dx be part of the primary or secondary dx?
Secondary
Abstract thinking
Adolescence
Bacterial infection

39. At patient that state their shoes are tighter at the end of the day may be experiencing
Fluid volume deficit related to poor intake
Have them do simple math problems
Edema
Pain on inspiration and expiration; superficial squeaking or grating

40. What are the ABCDE's of pain management?
Double check equip and patient
Trauma or illness
Ask - Believe - Choose - Deliver - Empower
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.

41. When speaking with a patient with moderate hearing loss the RN should
Capillaries
Pain on inspiration and expiration; superficial squeaking or grating
Communicate using hands and eyes.
Having to use more than one pillow when sleeping

42. Blood passes through the heart valves In what order?
Pain
Tricuspid - mitral and the aortic
The patient
Immature immune system - structures close together lends to easy spreading from on area to another.

43. An example of a primary source is
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Learning - memory and adaptation to stress
The patient
Pt's underlying feelings

44. Diabetes is a _________ dx
Medical
Vesicular (peripheral lung areas)
The process of storing - learning - retrieving - and using info.
Nursing dx

45. Data that is recorded for an immediate need (code blue or fall) would be included in
Decision assessment
Pain on inspiration and expiration; superficial squeaking or grating
Stroke volume x's heart rate
Medical

46. What is the formula for determining pack years?
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.
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
# of packs per day x # of years smoked

47. Expiration sounds are heard longer than inspiration In What area?
Broncial (heard over trachea)
The result is accurate patient dB
Pt's with oxygenation and perfusion problems
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve

48. What is intermittent claudication?
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Pain in legs assoc w walking
Disorganized thinking and altered LOC

49. A potential adverse rx of chemically restraining a confused patient would be
Preschool is cause and effect - school age begins to use logical thought process.
Paradoxical reaction
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
EdFED- Q

50. Hypogeusis is
Decision assessment
A false - fixed belief that cannot be corrected through reasoning.
Preschool is cause and effect - school age begins to use logical thought process.
Decreased sense of taste