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 (C)</p> Signup and view all the answers

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

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

What is the normal pH level range of stomach contents?

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

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

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

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

<p>Norton (A)</p> Signup and view all the answers

At what temperature is hypothermia defined?

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

Which site is NOT typically used to measure body temperature?

<p>Toes (B)</p> Signup and view all the answers

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

<p>Jugular (B)</p> Signup and view all the answers

Which symptom is associated with a Clostridium difficile infection?

<p>Diarrhoea (C)</p> Signup and view all the answers

What is a common sign of a urinary tract infection?

<p>Fever (C)</p> Signup and view all the answers

Which symptom is NOT associated with Clostridium difficile infection?

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

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

<p>Pyrexia (B)</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. (B)</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 (D)</p> Signup and view all the answers

What is tachycardia?

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

What is the normal respiratory rate range for an adult?

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

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

<p>Orthopnea (D)</p> Signup and view all the answers

Which of the following is a common sign of dyspnea?

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

What heart rate indicates tachycardia?

<p>100-120 bpm (D)</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 (A)</p> Signup and view all the answers

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

<p>Chills (B)</p> Signup and view all the answers

Which practice helps maintain dignity during personal hygiene?

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

What is aspiration?

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

Which condition can increase the risk of aspiration pneumonia?

<p>Poor dental hygiene (A)</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 (D)</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 (D)</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 (C)</p> Signup and view all the answers

What is a common symptom of hypertension?

<p>Facial flushing (A)</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 (A)</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 (C)</p> Signup and view all the answers

The presence of ketones in urine can indicate which condition?

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

Which alternative measurement can be used to determine height?

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

What is the primary purpose of enteral feeding?

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

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

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

Which condition is an indicator for enteral feeding?

<p>Dysphagia (B)</p> Signup and view all the answers

What is a significant risk associated with impaired swallowing?

<p>Aspiration (D)</p> Signup and view all the answers

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

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

What primarily influences cardiac output?

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

Which condition would likely lead to increased peripheral resistance?

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

How does blood volume affect blood pressure?

<p>Higher blood volume raises BP (D)</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 (A)</p> Signup and view all the answers

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

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

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

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

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

<p>Delays swallowing reflexes (B)</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) (A)</p> Signup and view all the answers

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

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

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

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

Flashcards

SSKIN Mnemonic

A system for reducing the risk of pressure ulcers by addressing factors like bedding, mobility, incontinence, and hydration.

Braden Scale

A tool that quantifies the risk of developing pressure sores based on sensory perception, moisture, mobility, nutrition, and friction.

Norton Scale

A tool that measures pressure sore risk by considering physical condition, mental state, activity, mobility, and incontinence.

Waterlow Score

A tool that calculates pressure sore risk considering body mass index, skin type, sex, age, and mobility.

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Skin Inspection

Regularly checking the skin for any signs of damage, such as redness, bruising, or breaks in the skin.

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Shell Temperature

The warmth at the skin surface.

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Core Temperature

The warmth in deeper sites of the body, like the brain and heart.

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Apical Pulse

The number of ventricular contractions per minute.

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Respiration

The exchange of oxygen and carbon dioxide.

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Orthopnea

Difficulty breathing that is relieved by sitting up.

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Stomach pH

The normal pH level of stomach contents, ranging from 2.5 to 3.5.

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Hypothermia

A body temperature below 35.0°C.

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5 Moments of Hand Hygiene

The 5 Moments of Hand Hygiene are a framework for ensuring that healthcare professionals wash their hands at the appropriate times to prevent the spread of infection.

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Temperature Measurement Sites

An area of the body where temperature can be measured.

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Carotid Pulse

A pulse point located in the neck near the carotid artery.

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Symptoms of C. difficile Infection

Diarrhea, nausea, fever, dehydration, and fast heart rate are common symptoms.

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Symptoms of a Urinary Tract Infection

Fever, back pain, abdominal cramps, difficulty urinating, foul-smelling urine, and blood in urine are common symptoms.

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Brachial Pulse

A pulse point located on the inner side of the elbow.

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Dyspnea

Difficulty breathing, often described as shortness of breath.

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Tachycardia

A rapid heart rate, often above 100 beats per minute.

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Proteinuria

The presence of protein in urine, often indicating kidney problems or nephrotic syndrome.

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High Fever

A fever with a body temperature above 39°C (102.2°F).

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Factors Affecting Oral Health in ID

Factors contributing to poor oral health in individuals with intellectual disabilities.

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Hypertension

A medical condition characterized by high pressure in the blood vessels, potentially leading to various health problems.

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MUST Tool

A test used to measure the overall risk of malnutrition in individuals. It involves evaluating BMI, weight loss, acute disease effects, and incorporating them into a scoring system.

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Tachypnea

A rapid and shallow breathing pattern, often caused by a lack of oxygen or high levels of carbon dioxide in the body. The rate is at least 20 breaths per minute.

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Ketones in Urine

The presence of ketones in the urine, indicating a potential condition like diabetic ketoacidosis or starvation.

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Alternative Height Measurements

Alternative measures used to estimate height in individuals where direct measurement is not feasible. They include ulna length, knee height, and demispan.

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Dysphagia

A condition where swallowing is difficult, making it easier for food or liquids to enter the airway.

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Role of RN in Aspiration Prevention

A registered nurse's key role in preventing aspiration includes careful assessment of the patient's swallowing abilities, creating tailored care plans to address individual needs, and implementing interventions like thickened liquids, positioning, and mealtime supervision.

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Why Vital Signs Are Important

These measurements track the body's basic functions and are important for detecting early signs of illness or deterioration. This information helps healthcare professionals make informed decisions about care.

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Manual Blood Pressure Measurement

This method involves using a sphygmomanometer and stethoscope to measure blood pressure. The cuff is placed on the upper arm, inflated, and then slowly deflated while listening for heartbeats.

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Percutaneous Endoscopic Gastrostomy (PEG) Feeding

Administering food and fluids through a tube directly into the stomach, bypassing the mouth and esophagus.

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Nasogastric (NG) Feeding

Administering food and fluids through a tube inserted into the nose and passed down the esophagus into the stomach.

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Enteral Feeding for Individuals with ID

Ensuring adequate nutrition when individuals have difficulty swallowing or are unable to meet their nutritional needs through oral intake.

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Dysphagia in ID

Difficulty swallowing, often caused by physical or neurological conditions. This can lead to food entering the airway instead of the esophagus.

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Cardiac Output and Blood Pressure

The amount of blood the heart pumps each minute. It is influenced by heart rate and stroke volume, with a higher cardiac output leading to increased blood pressure.

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Poor Oral Motor Control in ID

Individuals with intellectual disabilities often lack coordination of oral and pharyngeal muscles, leading to delayed swallowing reflexes or incomplete airway closure during swallowing.

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Peripheral Resistance and Blood Pressure

The force that blood encounters as it flows through blood vessels. Narrower vessels create greater resistance, leading to higher blood pressure, while dilated vessels decrease resistance and lower blood pressure.

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GERD in ID

Common in individuals with intellectual disabilities due to weak lower esophageal sphincter muscles. Stomach contents can back up into the airway, increasing the risk of aspiration.

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Blood Volume and Blood Pressure

The total volume of blood circulating in the body. Higher blood volume increases pressure, while lower blood volume decreases pressure.

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Artery Elasticity and Blood Pressure

Healthy arteries are elastic, accommodating blood flow. Stiff or hardened arteries (atherosclerosis) reduce blood flow and lead to higher blood pressure.

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Aspiration Risk in ID

The risk of aspiration refers to the possibility of food, liquid, or stomach contents entering the lungs instead of the digestive tract. This can cause serious complications.

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Venous Return and Blood Pressure

The return of blood from the body to the heart, ensuring adequate blood flow and cardiac output. Mechanisms like the skeletal muscle pump, respiratory pump, venous valves, and venoconstriction play a role in overcoming gravity and returning blood to the heart.

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Why ID Individuals are at High Risk for Aspiration

Individuals with intellectual disabilities are more prone to aspiration due to swallowing difficulties, poor oral motor control, and gastroesophageal reflux, all of which increase the likelihood of food or liquids entering the airways.

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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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