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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. Another term for a focused assessment is
Inattention and acute increase/decrease in cognitive function
Ongoing assessment
Bacterial infection
Abstract thinking

2. At What age do you begin to use logical thought process?
School age childen
Abstract thinking
Medical
ID'ing status of exisiting problems and locating new issues

3. A patient failing to answer questions or displaying a reluctance to participate in group or family activities may be experiencing
Upper airways
Nursing dx
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Hearing loss

4. Once a medical dx has been made - who is accountable for the reporting s/s of complications?
Assess over all health status and identify the problem
Nurse
To ID the problem
Loss of taste

5. A patient that is easily fatigued may have a HgB lab value of?
Implementation
Pt's underlying feelings
Broncial (heard over trachea)
8.4

6. The path of blood from the heart to the lungs is
Pain on inspiration and expiration; superficial squeaking or grating
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Vesicular (peripheral lung areas)
Paradoxical reaction

7. Keeping patient's belongings - shoes - suitcases and street clothes - etc. out of view are helpful for preventing: wandering?
Wandering
Focused
The medication will not affect the patient's breathing.
School age childen

8. Would a nursing dx be part of the primary or secondary dx?
Edema
Pain
Secondary
Viral infection

9. What scale is used to determine eating and feeding issues in adults with confusion
Pain in legs assoc w walking
Stroke volume x's heart rate
Medical
EdFED- Q

10. Fluid volume deficit is a __________ dx
Nursing
Upper airways
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Trend assessment (shift report)

11. What is the cognitive difference between a preschooler and schoolage child?
Family - spouse - someone other than a healthcare worker - previous medical records.
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Preschool is cause and effect - school age begins to use logical thought process.

12. Other factors that may indicate confusion using the CAM tool could be
8.4
The medication will not affect the patient's breathing.
A false - fixed belief that cannot be corrected through reasoning.
Disorganized thinking and altered LOC

13. What is the nursing process?
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Nursing
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Preschool is cause and effect - school age begins to use logical thought process.

14. Name the 5 'W's' of assessing a change in LOC
Tricuspid - mitral and the aortic
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
A personal experience that does whatever the person in pain says it does
Ask - Believe - Choose - Deliver - Empower

15. Where can you hear bronchovesicular breath sounds?
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
The patient
Risk of falls increases

16. When using restraints in a confused patient
Risk of falls increases
Medical
Having to use more than one pillow when sleeping
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts

17. Intermittent claudication is caused by?
Fluid volume deficit related to poor intake
Inattention and acute increase/decrease in cognitive function
The medication will not affect the patient's breathing.
Decreased arterial perfusion

18. When performing an ongoing assessment for a patient with disturbed thinking the nurse should be sure to include
Level of stress - risk for violence - anxiety level - patient unmet needs
No
The result is accurate patient dB
Maslow

19. At What age do you begin to use decision making?
Fluid volume deficit related to poor intake
Preschool is cause and effect - school age begins to use logical thought process.
Adolescence
Focused

20. Sleep deprivation can effect
Hemoglobin
ID'ing status of exisiting problems and locating new issues
Loss of taste
Learning - memory and adaptation to stress

21. An example of a primary source is
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
The patient
ID'ing status of exisiting problems and locating new issues
Secondary soureces (family - friends)

22. In Which part of the nursing process will you find delegation?
The patient
Have them do simple math problems
A false - fixed belief that cannot be corrected through reasoning.
Implementation

23. Side effects of putting confused pts in restraints include
Risk of falls increases
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Ongoing assessment
Fluid volume deficit related to poor intake

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

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25. The path of blood from the lungs to the heart is
The medication will not affect the patient's breathing.
Loss of taste
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Tricuspid - mitral and the aortic

26. Which patient would be most likely to experience sensory overload?
Preschool is cause and effect - school age begins to use logical thought process.
Paradoxical reaction
An 80 y/o patient that has emergency surgery
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins

27. Hypogeusis is
Maslow
Trend assessment (shift report)
Non - opiod (ex: NSAID/acetominaphen)
Decreased sense of taste

28. The purpose of an intitial assement serves to?
Assess over all health status and identify the problem
Pt's with oxygenation and perfusion problems
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
Trauma or illness

29. What are Piaget's stages of cognitive development
Decision assessment
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
Pain in legs assoc w walking
Immature immune system - structures close together lends to easy spreading from on area to another.

30. What is the formula for cardiac output?

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31. What do rhonchi sound like?
Family - spouse - someone other than a healthcare worker - previous medical records.
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Decreased arterial perfusion
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts

32. Are changes in vital signs a reliable indicator of chronic pain?
Learning - memory and adaptation to stress
Defining a baseline of cognitive function - any changes or deviations from norm.
No
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)

33. Nursing interventions should be based on who's theory?
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Maslow
Ongoing assessment
Fluid volume deficit related to poor intake

34. One way to test a person's cognitive ability and abstract thinking ability would be to
Adolescence
Have them do simple math problems
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Immature immune system - structures close together lends to easy spreading from on area to another.

35. Expiration sounds are heard longer than inspiration In What area?
School age childen
Paradoxical reaction
Broncial (heard over trachea)
Decision assessment

36. What is cognition?
8.4
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
The process of storing - learning - retrieving - and using info.
Stroke volume x's heart rate

37. What is the purpose of the nursing process?
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Serves to expedite dx and tx of actual and potential health problems
Pain on inspiration and expiration; superficial squeaking or grating
# of packs per day x # of years smoked

38. When a patient has increased lymphocytes - this may indicate what?
Irregular respirations (fast/slow) often seen at end of life
Daily
Viral infection
Fast and deep respirations seen in patient's with acidosis

39. What is pain?
A personal experience that does whatever the person in pain says it does
The result is accurate patient dB
Bacterial infection
Pain

40. At patient that state their shoes are tighter at the end of the day may be experiencing
Edema
Inattention and acute increase/decrease in cognitive function
Fluid volume deficit related to poor intake
Objective

41. Ongoing assessments are useful in

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42. What factors may indicate plural rub?
Pain on inspiration and expiration; superficial squeaking or grating
Tricuspid - mitral and the aortic
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Secondary

43. Data that is recorded for an immediate need (code blue or fall) would be included in
An 80 y/o patient that has emergency surgery
Decision assessment
Hearing loss
Ask - Believe - Choose - Deliver - Empower

44. Subjective data could include
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
Symptoms
Defining a baseline of cognitive function - any changes or deviations from norm.
Initial assessment

45. What is the difference between a nursing dx and a med dx?
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
8.4
Risk of falls increases

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

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47. Ageusia is
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
The result is accurate patient dB
Knowing What to do/how to make a decision based upon available data.
Loss of taste

48. 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)
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
A personal experience that does whatever the person in pain says it does
The result is accurate patient dB

49. If an abnormal finding is revealed during assessment - the nurse should
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Double check equip and patient
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Hemoglobin

50. Orthopnea is described as?
A false - fixed belief that cannot be corrected through reasoning.
Pain
Having to use more than one pillow when sleeping
Bacterial infection

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Nursing Fundamentals 3

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