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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. The assessment that includes the patient's overhall health status
Initial assessment
Interventions for which the nurse is accountable
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Stroke volume x's heart rate

2. What are the ABCDE's of pain management?
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Ask - Believe - Choose - Deliver - Empower
Risk of falls increases
Double check equip and patient

3. What is responsible for transporting O2 in the blood
Hemoglobin
Fast and deep respirations seen in patient's with acidosis
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
EdFED- Q

4. 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.
Pain
The process of storing - learning - retrieving - and using info.
Inattention and acute increase/decrease in cognitive function

5. Ageusia is
The result is accurate patient dB
Loss of taste
EdFED- Q
Defining a baseline of cognitive function - any changes or deviations from norm.

6. Where can you hear bronchovesicular breath sounds?
Upper airways
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Inattention and acute increase/decrease in cognitive function
Pain

7. What is a component of the cognitive part of critical thinking skills?
Medical
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
Stroke volume x's heart rate
Knowing What to do/how to make a decision based upon available data.

8. What is intermittent claudication?
Pain in legs assoc w walking
Having to use more than one pillow when sleeping
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
No

9. If patient reports pain of 3 on scale of 0-10 - What is the appropriate class of pain reliever?
Non - opiod (ex: NSAID/acetominaphen)
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
Decision assessment
Secondary

10. At What age do you begin to put thoughts into words?
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
Toddler
Decreased arterial perfusion
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital

11. What would cause changes in congitive development later in life (middle adulthood)?
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Pain
Trauma or illness

12. When performing an interview with a patient with vision loss - select the correct questions for obtaining an accurate vision history
Communicate using hands and eyes.
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Irregular respirations (fast/slow) often seen at end of life
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.

13. At What age do you begin to use decision making?
Non - opiod (ex: NSAID/acetominaphen)
ID'ing status of exisiting problems and locating new issues
Adolescence
Nursing dx

14. An example of a nursing dx would be
Fluid volume deficit related to poor intake
Tricuspid - mitral and the aortic
Bacterial infection
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.

15. Describe the purpose of a mental status exam
Defining a baseline of cognitive function - any changes or deviations from norm.
Stroke volume x's heart rate
8.4
Having to use more than one pillow when sleeping

16. Nursing dx provides basis of
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
Have them do simple math problems
Immature immune system - structures close together lends to easy spreading from on area to another.
Interventions for which the nurse is accountable

17. What are the components of an assessment?
Knowing What to do/how to make a decision based upon available data.
Decreased arterial perfusion
Focused
Data collection - data validation - data organization - data analysis - and data reporting/recording.

18. Which patient would be most likely to experience sensory overload?
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
An 80 y/o patient that has emergency surgery

19. Asking a patient what would you do if there is a fire in the wastebasket - is a way to assess their
Abstract thinking
Irregular respirations (fast/slow) often seen at end of life
A false - fixed belief that cannot be corrected through reasoning.
Initial assessment

20. Would a nursing dx be part of the primary or secondary dx?
Nursing
Secondary
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Pain

21. Expiration sounds are heard longer than inspiration In What area?
Implementation
Decreased arterial perfusion
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Broncial (heard over trachea)

22. At patient that state their shoes are tighter at the end of the day may be experiencing
Edema
No
Daily
Preschool is cause and effect - school age begins to use logical thought process.

23. What is the correct approach when dealing with older adults?
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Medical
Vesicular (peripheral lung areas)
Disorganized thinking and altered LOC

24. Orthopnea is described as?
Having to use more than one pillow when sleeping
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
A false - fixed belief that cannot be corrected through reasoning.
Sensory motor

25. 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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26. Types of hearing loss include
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
Secondary soureces (family - friends)
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Tricuspid - mitral and the aortic

27. Acceptable sources of assessment data when evaluating a confused patient would be
Secondary soureces (family - friends)
8.4
Decreased sense of taste
School age childen

28. Are changes in vital signs a reliable indicator of chronic pain?
No
Nursing
Paradoxical reaction
School age childen

29. The path of blood from the heart to the lungs is
8.4
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Non - opiod (ex: NSAID/acetominaphen)
Wandering

30. Two indicators that are REQUIRED for classification via the CAM tool include
Ask - Believe - Choose - Deliver - Empower
Trend assessment (shift report)
Irregular respirations (fast/slow) often seen at end of life
Inattention and acute increase/decrease in cognitive function

31. What do rhonchi sound like?
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Focused
School age childen
The process of storing - learning - retrieving - and using info.

32. The path of blood from the lungs to the heart is
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
To simulate eating motions with the hands
8.4
Serves to expedite dx and tx of actual and potential health problems

33. Data that is recorded for an immediate need (code blue or fall) would be included in
Decision assessment
8.4
EdFED- Q
Secondary soureces (family - friends)

34. Subjective data could include
Pain
The medication will not affect the patient's breathing.
Pt's underlying feelings
Symptoms

35. Data from the last 24/48 hours that included patterns would be a part of
Trend assessment (shift report)
Wandering
Pain
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)

36. QUESTT is a tool for What type of an assessment?
Pain
Adolescence
Loss of taste
A false - fixed belief that cannot be corrected through reasoning.

37. One way to test a person's cognitive ability and abstract thinking ability would be to
Toddler
Have them do simple math problems
To simulate eating motions with the hands
# of packs per day x # of years smoked

38. Nursing interventions should be based on who's theory?
Pain
A false - fixed belief that cannot be corrected through reasoning.
Maslow
Nursing dx

39. Another term for a focused assessment is
Risk of falls increases
Communicate using hands and eyes.
Ongoing assessment
Upper airways

40. What is cognition?
Knowing What to do/how to make a decision based upon available data.
The process of storing - learning - retrieving - and using info.
8.4
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli

41. An infant is in which Paiget stage?
Sensory motor
Edema
Fluid volume deficit related to poor intake
Adolescence

42. Intermittent claudication is caused by?
Decreased arterial perfusion
Preschool is cause and effect - school age begins to use logical thought process.
Pain on inspiration and expiration; superficial squeaking or grating
Learning - memory and adaptation to stress

43. The purpose of an intitial assement serves to?
To simulate eating motions with the hands
A false - fixed belief that cannot be corrected through reasoning.
Assess over all health status and identify the problem
The medication will not affect the patient's breathing.

44. When speaking with a patient with moderate hearing loss the RN should
Irregular respirations (fast/slow) often seen at end of life
Focused
Communicate using hands and eyes.
Maslow

45. Keeping patient's belongings - shoes - suitcases and street clothes - etc. out of view are helpful for preventing: wandering?
Serves to expedite dx and tx of actual and potential health problems
Wandering
EdFED- Q
Pain on inspiration and expiration; superficial squeaking or grating

46. A potential adverse rx of chemically restraining a confused patient would be
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Paradoxical reaction
Ongoing assessment

47. At What age do you begin to use logical thought process?
An 80 y/o patient that has emergency surgery
Non - opiod (ex: NSAID/acetominaphen)
School age childen
Wandering

48. A patient that is easily fatigued may have a HgB lab value of?
8.4
Nursing dx
EdFED- Q
Bacterial infection

49. The basis for a plan of care comes for which stage of the nursing process?
Edema
Nursing dx
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Hemoglobin

50. Where can wheezes best be heard?
Upper airways
Pain in legs assoc w walking
Adolescence
The medication will not affect the patient's breathing.