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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.
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. Where can wheezes best be heard?
Objective
Upper airways
To simulate eating motions with the hands
The result is accurate patient dB

2. When performing an interview with a patient with vision loss - select the correct questions for obtaining an accurate vision history
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.
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Eye hygeine - accomodating factors - what was the level of decline - how long has it been

3. Asking a patient what would you do if there is a fire in the wastebasket - is a way to assess their
Initial assessment
Abstract thinking
Maslow
Family - spouse - someone other than a healthcare worker - previous medical records.

4. Side effects of putting confused pts in restraints include
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Capillaries
ID'ing status of exisiting problems and locating new issues
Level of stress - risk for violence - anxiety level - patient unmet needs

5. Once a medical dx has been made - who is accountable for the reporting s/s of complications?
Nurse
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Maslow
Upper airways

6. What scale is used to determine eating and feeding issues in adults with confusion
EdFED- Q
Symptoms
Secondary soureces (family - friends)
Daily

7. When a patient has increased lymphocytes - this may indicate what?
The patient
Viral infection
Hemoglobin
Pt's underlying feelings

8. A nursing dx is best described as
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
To simulate eating motions with the hands
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital

9. All body system data is not necessary which type of assessment
Toddler
Implementation
Focused
Daily

10. An ongoing assessment is performed
A personal experience that does whatever the person in pain says it does
School age childen
Daily
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation

11. What does CAM stand for
Defining a baseline of cognitive function - any changes or deviations from norm.
Pain in legs assoc w walking
Confusion Assessment Method
Nursing

12. What is the cognitive difference between a preschooler and schoolage child?
Implementation
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Preschool is cause and effect - school age begins to use logical thought process.
Nursing dx

13. Ageusia is
Objective
Snap - crackle - pops; velcro - bubble wrap
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Loss of taste

14. Other factors that may indicate confusion using the CAM tool could be
Disorganized thinking and altered LOC
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
The patient
The result is accurate patient dB

15. Name the 5 'W's' of assessing a change in LOC
Bacterial infection
Fast and deep respirations seen in patient's with acidosis
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)

16. 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
Risk of falls increases
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Have them do simple math problems

17. Nursing dx provides basis of
# of packs per day x # of years smoked
Interventions for which the nurse is accountable
Objective
Toddler

18. Blood passes through the heart valves In what order?
Objective
Serves to expedite dx and tx of actual and potential health problems
Tricuspid - mitral and the aortic
Stroke volume x's heart rate

19. Are changes in vital signs a reliable indicator of chronic pain?
Irregular respirations (fast/slow) often seen at end of life
Confusion Assessment Method
Have them do simple math problems
No

20. A potential adverse rx of chemically restraining a confused patient would be
Knowing What to do/how to make a decision based upon available data.
No
Non - opiod (ex: NSAID/acetominaphen)
Paradoxical reaction

21. At What age do you begin to put thoughts into words?
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
Toddler
Bacterial infection

22. The purpose of an intitial assement serves to?
Secondary
Assess over all health status and identify the problem
Knowing What to do/how to make a decision based upon available data.
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts

23. The order of air flow into the lungs is
Tricuspid - mitral and the aortic
Double check equip and patient
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
Trend assessment (shift report)

24. Another term for a focused assessment is
Trend assessment (shift report)
Ongoing assessment
Have them do simple math problems
Stroke volume x's heart rate

25. What would cause changes in congitive development later in life (middle adulthood)?
8.4
Trauma or illness
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy

26. Examples of personal information
Learning - memory and adaptation to stress
Vesicular (peripheral lung areas)
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Hygeine - DOB - work hx

27. Diabetes is a _________ dx
Decision assessment
Hearing loss
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Medical

28. An example of a primary source is
Broncial (heard over trachea)
The patient
Pain
Fast and deep respirations seen in patient's with acidosis

29. If patient reports pain of 3 on scale of 0-10 - What is the appropriate class of pain reliever?
Paradoxical reaction
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
Ask - Believe - Choose - Deliver - Empower
Non - opiod (ex: NSAID/acetominaphen)

30. Inspiration sounds are heard longer than expiration sounds In What area?
Focused
Vesicular (peripheral lung areas)
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Eye hygeine - accomodating factors - what was the level of decline - how long has it been

31. When a patient has increased neutrophils - this may indicate what?
Decreased arterial perfusion
Bacterial infection
Focused
Non - opiod (ex: NSAID/acetominaphen)

32. What is cognition?
Data collection - data validation - data organization - data analysis - and data reporting/recording.
The process of storing - learning - retrieving - and using info.
Implementation
Ask - Believe - Choose - Deliver - Empower

33. When using restraints in a confused patient
Hemoglobin
Hearing loss
ID'ing status of exisiting problems and locating new issues
Risk of falls increases

34. An infant is in which Paiget stage?
The process of storing - learning - retrieving - and using info.
Trend assessment (shift report)
Secondary soureces (family - friends)
Sensory motor

35. In Which part of the nursing process will you find delegation?
Sensory motor
Learning - memory and adaptation to stress
Implementation
Bacterial infection

36. What is a component of the cognitive part of critical thinking skills?
Pain in legs assoc w walking
Knowing What to do/how to make a decision based upon available data.
Ongoing assessment
Decreased sense of taste

37. Hypogeusis is
Decreased arterial perfusion
Pain in legs assoc w walking
Decreased sense of taste
Risk of falls increases

38. What are Cheyne Stokes?
Hearing loss
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
Trauma or illness
Irregular respirations (fast/slow) often seen at end of life

39. 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.
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Medical
Decision assessment

40. A patient failing to answer questions or displaying a reluctance to participate in group or family activities may be experiencing
Trend assessment (shift report)
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Ask - Believe - Choose - Deliver - Empower
Hearing loss

41. Data validation assures
The result is accurate patient dB
To simulate eating motions with the hands
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Have them do simple math problems

42. What is the purpose of the nursing process?
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Nursing dx
Serves to expedite dx and tx of actual and potential health problems
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve

43. Keeping patient's belongings - shoes - suitcases and street clothes - etc. out of view are helpful for preventing: wandering?
Snap - crackle - pops; velcro - bubble wrap
School age childen
Pain
Wandering

44. What are the ABCDE's of pain management?
Irregular respirations (fast/slow) often seen at end of life
Decision assessment
Ask - Believe - Choose - Deliver - Empower
A false - fixed belief that cannot be corrected through reasoning.

45. The site where gas exchange occurs is
Focused
Preschool is cause and effect - school age begins to use logical thought process.
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Capillaries

46. Where can you hear bronchovesicular breath sounds?
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Abstract thinking
8.4
Decreased sense of taste

47. The purpose of an initial assessment is
To ID the problem
Paradoxical reaction
Loss of taste
Having to use more than one pillow when sleeping

48. Kussamaul respirations describe

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

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50. Intermittent claudication is caused by?
Decreased arterial perfusion
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Pt's underlying feelings
Serves to expedite dx and tx of actual and potential health problems

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Nursing Fundamentals 3

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