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Nursing Fundamentals 3

Instructions:

Answer 50 questions in 15 minutes.
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Match each statement with the correct term.
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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 is intermittent claudication?
Knowing What to do/how to make a decision based upon available data.
EdFED- Q
Implementation
Pain in legs assoc w walking

2. Ongoing assessments are useful in

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3. Where can you hear bronchovesicular breath sounds?
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Pt's with oxygenation and perfusion problems
Maslow
The patient

4. At What age do you begin to use decision making?
Adolescence
A personal experience that does whatever the person in pain says it does
Nursing dx
Inattention and acute increase/decrease in cognitive function

5. What is the formula for determining pack years?
Symptoms
# of packs per day x # of years smoked
Fast and deep respirations seen in patient's with acidosis
Learning - memory and adaptation to stress

6. An example of a secondary source is
ID'ing status of exisiting problems and locating new issues
Immature immune system - structures close together lends to easy spreading from on area to another.
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
Family - spouse - someone other than a healthcare worker - previous medical records.

7. Examples of personal information
Hygeine - DOB - work hx
Defining a baseline of cognitive function - any changes or deviations from norm.
Tricuspid - mitral and the aortic
Stroke volume x's heart rate

8. What do rhonchi sound like?
Pain in legs assoc w walking
Interventions for which the nurse is accountable
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

9. The purpose of an initial assessment is
To simulate eating motions with the hands
To ID the problem
Ask - Believe - Choose - Deliver - Empower
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.

10. A potential adverse rx of chemically restraining a confused patient would be
Paradoxical reaction
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Sensory motor
Nursing dx

11. What are the steps of the nursing process?
Fast and deep respirations seen in patient's with acidosis
Objective
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Disorganized thinking and altered LOC

12. Orthopnea is described as?
Decreased sense of taste
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Having to use more than one pillow when sleeping
Pain

13. At What age do you begin to put thoughts into words?
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Double check equip and patient
Toddler
Immature immune system - structures close together lends to easy spreading from on area to another.

14. The site where gas exchange occurs is
Capillaries
Abstract thinking
No
Nurse

15. When speaking with a patient with moderate hearing loss the RN should
Communicate using hands and eyes.
EdFED- Q
Nursing dx
Confusion Assessment Method

16. QUESTT is a tool for What type of an assessment?
Decreased arterial perfusion
Double check equip and patient
ID'ing status of exisiting problems and locating new issues
Pain

17. What do rales sound like?
Pain on inspiration and expiration; superficial squeaking or grating
Nursing dx
Trauma or illness
Snap - crackle - pops; velcro - bubble wrap

18. Ageusia is
Ask - Believe - Choose - Deliver - Empower
Nursing
Having to use more than one pillow when sleeping
Loss of taste

19. Nursing dx provides basis of
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Interventions for which the nurse is accountable
Fast and deep respirations seen in patient's with acidosis

20. Kussamaul respirations describe

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21. When a patient has increased lymphocytes - this may indicate what?
Decreased arterial perfusion
Tricuspid - mitral and the aortic
Viral infection
An 80 y/o patient that has emergency surgery

22. Nursing interventions should be based on who's theory?
Pain on inspiration and expiration; superficial squeaking or grating
Maslow
Decision assessment
Fluid volume deficit related to poor intake

23. When performing an interview with a patient with vision loss - select the correct questions for obtaining an accurate vision history
Hearing loss
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
Confusion Assessment Method

24. Once a medical dx has been made - who is accountable for the reporting s/s of complications?
Nurse
Bacterial infection
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Snap - crackle - pops; velcro - bubble wrap

25. What does CAM stand for
A false - fixed belief that cannot be corrected through reasoning.
Inattention and acute increase/decrease in cognitive function
Secondary
Confusion Assessment Method

26. Diabetes is a _________ dx
Fast and deep respirations seen in patient's with acidosis
Symptoms
Hygeine - DOB - work hx
Medical

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. What are the components of an assessment?
Vesicular (peripheral lung areas)
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Risk of falls increases

29. Types of hearing loss include
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)
Initial assessment
Bacterial infection

30. Name the 5 'W's' of assessing a change in LOC
Adolescence
Initial assessment
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
To simulate eating motions with the hands

31. Data gathered via instrumention (pulse ox) is considered
Trend assessment (shift report)
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Objective

32. All body system data is not necessary which type of assessment
Toddler
Focused
Bacterial infection
Pt's underlying feelings

33. Keeping patient's belongings - shoes - suitcases and street clothes - etc. out of view are helpful for preventing: wandering?
Interventions for which the nurse is accountable
Wandering
Family - spouse - someone other than a healthcare worker - previous medical records.
Objective

34. What is a chochlear implant?
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Medical
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Fluid volume deficit related to poor intake

35. Subjective data could include
Symptoms
8.4
Hearing loss
Secondary soureces (family - friends)

36. A nursing dx is best described as
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Pt's with oxygenation and perfusion problems
Focused
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.

37. Intermittent claudication is caused by?
Disorganized thinking and altered LOC
Decreased arterial perfusion
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Immature immune system - structures close together lends to easy spreading from on area to another.

38. Factors that may reduce the efficacy of pulse oximetry include
The process of storing - learning - retrieving - and using info.
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Knowing What to do/how to make a decision based upon available data.

39. Inspiration sounds are heard longer than expiration sounds In What area?
Vesicular (peripheral lung areas)
To ID the problem
Decision assessment
Broncial (heard over trachea)

40. One way to test a person's cognitive ability and abstract thinking ability would be to
The process of storing - learning - retrieving - and using info.
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Have them do simple math problems
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.

41. What is the nursing process?
Pain
Hygeine - DOB - work hx
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.

42. An example of a primary source is
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
The patient
Preschool is cause and effect - school age begins to use logical thought process.

43. When a patient has increased neutrophils - this may indicate what?
Bacterial infection
Trauma or illness
Preschool is cause and effect - school age begins to use logical thought process.
Data collection - data validation - data organization - data analysis - and data reporting/recording.

44. Describe the purpose of a mental status exam
Defining a baseline of cognitive function - any changes or deviations from norm.
Pain in legs assoc w walking
Adolescence
Wandering

45. The path of blood from the heart to the lungs is
Decreased arterial perfusion
The result is accurate patient dB
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Trauma or illness

46. Other factors that may indicate confusion using the CAM tool could be
Broncial (heard over trachea)
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Disorganized thinking and altered LOC
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation

47. What are the components of a mental status exam that are not part of a regular assessment?
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
Hemoglobin
Hygeine - DOB - work hx
Adolescence

48. Are changes in vital signs a reliable indicator of chronic pain?
No
Bacterial infection
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Pain in legs assoc w walking

49. If an abnormal finding is revealed during assessment - the nurse should
Bacterial infection
Loss of taste
Double check equip and patient
Data collection - data validation - data organization - data analysis - and data reporting/recording.

50. Data validation assures
Loss of taste
Viral infection
The result is accurate patient dB
Implementation

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Nursing Fundamentals 3

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