Nursing Assessment and Care Quiz
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Questions and Answers

What does the 'S' in the SSKIN mnemonic stand for?

  • Skin inspections
  • Safety
  • Support
  • Surface (correct)
  • Which scale does NOT include moisture as a component for assessing pressure sore risk?

  • Norton Scale
  • Skin Condition Index (correct)
  • Waterlow Score
  • Braden Scale
  • Which factor is considered in the Waterlow Score?

  • Mental state
  • Skin type (correct)
  • Hydration level
  • Friction
  • In the Braden Scale, which element is related to risk assessment?

    <p>Mobility</p> Signup and view all the answers

    What is a key recommendation in the SSKIN mnemonic regarding movement?

    <p>Encourage movement</p> Signup and view all the answers

    What is the normal pH level range of stomach contents?

    <p>2.5 - 3.5</p> Signup and view all the answers

    Which of the following is NOT one of the 5 moments of hand hygiene?

    <p>Before eating</p> Signup and view all the answers

    Which risk assessment tool is used for evaluating pressure sore risk?

    <p>Norton</p> Signup and view all the answers

    At what temperature is hypothermia defined?

    <p>35.0°</p> Signup and view all the answers

    Which site is NOT typically used to measure body temperature?

    <p>Toes</p> Signup and view all the answers

    Which of the following is NOT a pulse point of the body?

    <p>Jugular</p> Signup and view all the answers

    Which symptom is associated with a Clostridium difficile infection?

    <p>Diarrhoea</p> Signup and view all the answers

    What is a common sign of a urinary tract infection?

    <p>Fever</p> Signup and view all the answers

    Which symptom is NOT associated with Clostridium difficile infection?

    <p>Back pain</p> Signup and view all the answers

    Which of the following is a symptom of a urinary tract infection?

    <p>Pyrexia</p> Signup and view all the answers

    What is the primary function of the hypothalamus in relation to body temperature?

    <p>It regulates body temperature.</p> Signup and view all the answers

    Which of the following ranges represents the normal body temperature in Celsius?

    <p>36.4°C to 37.3°C</p> Signup and view all the answers

    What is tachycardia?

    <p>A fast heart rate between 100 to 150 beats per minute.</p> Signup and view all the answers

    What is the normal respiratory rate range for an adult?

    <p>14-20 breaths per minute</p> Signup and view all the answers

    What condition is characterized by difficulty breathing that is relieved by sitting up?

    <p>Orthopnea</p> Signup and view all the answers

    Which of the following is a common sign of dyspnea?

    <p>Shortness of breath</p> Signup and view all the answers

    What heart rate indicates tachycardia?

    <p>100-120 bpm</p> Signup and view all the answers

    Which option is NOT a factor predisposing poor oral health in individuals with intellectual disabilities?

    <p>Social interaction</p> Signup and view all the answers

    What symptom is indicative of a body temperature above 39°C?

    <p>Chills</p> Signup and view all the answers

    Which practice helps maintain dignity during personal hygiene?

    <p>Asking for permission to assist</p> Signup and view all the answers

    What is aspiration?

    <p>Swallowing food that enters the airway or lungs</p> Signup and view all the answers

    Which condition can increase the risk of aspiration pneumonia?

    <p>Poor dental hygiene</p> Signup and view all the answers

    What is one of the roles of a registered nurse (RN) in managing aspiration risk?

    <p>Creating care plans based on assessments</p> Signup and view all the answers

    What is the first step in taking a manual blood pressure measurement?

    <p>Positioning the cuff on the upper arm</p> Signup and view all the answers

    Why are vital signs important in risk determination?

    <p>They are indicators of overall health and signal potential deterioration</p> Signup and view all the answers

    What is a common symptom of hypertension?

    <p>Facial flushing</p> Signup and view all the answers

    Which of the following is NOT a step in the MUST Tool for assessing malnutrition?

    <p>Perform a blood test</p> Signup and view all the answers

    What condition is indicated by a respiration rate greater than or equal to 20 breaths per minute?

    <p>Tachypnea</p> Signup and view all the answers

    The presence of ketones in urine can indicate which condition?

    <p>Diabetic ketoacidosis</p> Signup and view all the answers

    Which alternative measurement can be used to determine height?

    <p>Knee height</p> Signup and view all the answers

    What is the primary purpose of enteral feeding?

    <p>To administer nutrients directly into the gastrointestinal tract</p> Signup and view all the answers

    Which enteral feeding method is most suitable for long-term nutrition?

    <p>Percutaneous Enteral Gastrostomy (PEG)</p> Signup and view all the answers

    Which condition is an indicator for enteral feeding?

    <p>Dysphagia</p> Signup and view all the answers

    What is a significant risk associated with impaired swallowing?

    <p>Aspiration</p> Signup and view all the answers

    Which of the following is NOT a method of enteral feeding?

    <p>Subcutaneous Feeding</p> Signup and view all the answers

    What primarily influences cardiac output?

    <p>Heart rate and stroke volume</p> Signup and view all the answers

    Which condition would likely lead to increased peripheral resistance?

    <p>Constriction of blood vessels</p> Signup and view all the answers

    How does blood volume affect blood pressure?

    <p>Higher blood volume raises BP</p> Signup and view all the answers

    What role does the elasticity of arteries play in blood pressure?

    <p>Elasticity of arteries helps accommodate blood flow, affecting BP</p> Signup and view all the answers

    Which mechanism is primarily responsible for venous return to the heart?

    <p>Skeletal muscle pump</p> Signup and view all the answers

    What is a common condition that contributes to dysphagia in individuals with intellectual disabilities?

    <p>Cerebral palsy</p> Signup and view all the answers

    How does poor oral motor control affect individuals with intellectual disabilities?

    <p>Delays swallowing reflexes</p> Signup and view all the answers

    What physiological issue is common in individuals with intellectual disabilities that can lead to aspiration?

    <p>Gastroesophageal reflux disease (GERD)</p> Signup and view all the answers

    What is a consequence of repeated aspiration incidents in individuals with intellectual disabilities?

    <p>Chronic respiratory issues</p> Signup and view all the answers

    Why do individuals with intellectual disabilities often experience aspiration of secretions?

    <p>Weak swallowing muscles</p> Signup and view all the answers

    Study Notes

    Implementation: Use the Skin mnemonic

    • Surface = ensure proper bedding
    • Skin inspections = regular checks for skin integrity
    • Keep mobile = encourage movement
    • Incontinence = manage moisture effectively
    • Nutrition = ensure adequate hydration and nutrition

    Pressure Sore Risk Assessment Tools

    • Braden Scale:

      • Assesses risk based on sensory perception
      • Moisture
      • Mobility
      • Nutrition
      • Friction
    • Norton Scale:

      • Evaluates physical condition
      • Mental state
      • Activity
      • Mobility
      • Incontinence
    • Waterlow Score:

      • Considers body mass index
      • Skin type
      • Sex
      • Age
      • Mobility to determine risk

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    Description

    Test your knowledge on essential nursing assessment tools and care practices. This quiz covers various topics, including pressure sore risk assessments, hand hygiene, and physiological norms. Perfect for nursing students or professionals looking to refresh their knowledge.

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