Nursing Assessment Quiz

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Questions and Answers

What are the symptoms of BPH?

Nocturia (correct)

Straining to void (correct)

Voiding difficulty and urgency (correct)

Burning with urination

What is the preferred positioning for a patient with altered level of consciousness?

Side lying position

What are the symptoms of septic shock?

Tachycardia, fever, hypotension, pallor, fatigue, cold, reduced urine output, shortness of breath, decreased level of consciousness, nausea/vomiting, sweating

What is the most reliable indicator of neurological status?

Level of consciousness Signup and view all the answers

What virus is responsible for Herpes Zoster?

VZV virus Signup and view all the answers

What is the survival rate for a patient with amyotrophic lateral sclerosis (ALS)?

3-5 years Signup and view all the answers

What is the first action to implement in a burn patient?

ABCs and fluids Signup and view all the answers

What are Cushing's triad symptoms?

Bradycardia, increased systolic blood pressure, and irregular respirations Signup and view all the answers

What should be used to withdraw medication from an ampule?

Filter needle Signup and view all the answers

What is receptive aphasia?

Inability to understand spoken or written words Signup and view all the answers

Where is the hotspot injection site for Enoxaparin?

Right or left side of abdomen, 2 inches from belly button Signup and view all the answers

What should be monitored for abdominal wound healing?

Docusate, nausea treatment, pillow to cough, abdominal binder, and blood sugar Signup and view all the answers

What are isotonic fluids used for?

Fluid resuscitation, hypovolemic shock, and dehydration Signup and view all the answers

How should a blind person be assisted while walking?

Walk slightly ahead and to the side with their hand on your elbow Signup and view all the answers

How is medication measured for pediatric clients?

Oral syringe Signup and view all the answers

What is the technique for dressing someone with a stroke?

Affected side first Signup and view all the answers

What are the signs and symptoms of Systemic Lupus Erythematosus (SLE)?

Elevated ESR, positive ANA, decreased WBC count, thrombocytopenia, anemia Signup and view all the answers

What should be done to care for a halo device?

Clean pin sites with sterile solution and keep vest liner dry Signup and view all the answers

What should be increased in lithotripsy?

Fluid intake Signup and view all the answers

What is the RICE method for sprain treatment?

Rest, Ice, Compression, Elevation Signup and view all the answers

What is the technique for pursed lip breathing?

Inhale for 2 seconds through the nose and exhale for 4 seconds through pursed lips Signup and view all the answers

What are the symptoms of a hip fracture?

Externally rotates, muscle spasm, bruising, shortening of limb, pain with weight bearing Signup and view all the answers

What is cephalohematoma?

Normal bruising Signup and view all the answers

What is physiological jaundice of the newborn?

Hyperbilirubinemia occurring after 24 hours Signup and view all the answers

What class of drugs does magnesium sulfate belong to?

Tocolytics Signup and view all the answers

What is the indication for Betamethasone?

Fetal lung maturity in preterm labor Signup and view all the answers

What should be the total weight gain during a normal pregnancy?

28 lb +/- 3 lbs Signup and view all the answers

What are the effects of Methergine/ergometrine?

Can cause hypertension in mother Signup and view all the answers

What is the action of terbutaline in pregnancy?

Relaxes uterus and stops preterm labor Signup and view all the answers

What is pathological jaundice?

Occurs before 24 hours and may indicate early hemolysis Signup and view all the answers

What is caput succedaneum?

Bruise that crosses sutures and is symmetrical Signup and view all the answers

What does erythema toxicum neonatorum look like?

Benign papular rash Signup and view all the answers

Which tranquilizer/psych medication is safe during pregnancy?

Haldol Signup and view all the answers

What are probably signs of pregnancy?

Chadwick's, Goodell's, and Hegar's signs Signup and view all the answers

What is the latent phase of labor?

0-4 dilation, contractions every 5-30 minutes Signup and view all the answers

What is important to remember about pain medications in labor?

Do not give a pain med right before the baby is born Signup and view all the answers

What should you do with a prolapsed cord?

Push and position! Signup and view all the answers

What do variable decelerations indicate?

Very bad - it may indicate cord prolapse Signup and view all the answers

What is significant about the placenta's vessels?

3 vessels - 2 arteries and 1 vein Signup and view all the answers

What must a baby have before leaving the delivery area?

An ID band immediately Signup and view all the answers

What should you check if unsure on an OB question?

Fetal heart rate (FHR) Signup and view all the answers

What is the VEAL CHOP mnemonic used for?

Variable Cord compression, Early decels Head compression, Accelerations Ok, Late decels Placental insufficiency Signup and view all the answers

What should be done if the FHR tracing starts with L?

LION Signup and view all the answers

What are late decelerations on FHR indicative of?

Bad, indicating potential issues Signup and view all the answers

What is high baseline variability?

6-25 point variability - this is good Signup and view all the answers

What does low baseline variability on FHR mean?

FHR stays the same and is not changing Signup and view all the answers

What is high fetal heart rate (FHR)?

<blockquote> 160 </blockquote> Signup and view all the answers

What does low fetal heart rate on monitor indicate?

Requires further assessment Signup and view all the answers

Study Notes

BPH Assessment

Symptoms include voiding difficulty, urgency, incomplete emptying, straining to void, and nocturia.
Urinary burning indicates a UTI, unrelated to sexual intercourse.
A score above 50 highlights assessment concerns.

Altered Level of Consciousness Positioning

Position patients with altered consciousness in a side-lying position to maintain airway safety.

Septic Shock Symptoms

Detect tachycardia, fever, hypotension (systolic <90), pallor, fatigue, cold skin, reduced urine output, shortness of breath, decreased level of consciousness, nausea/vomiting, and sweating.

Neurological Status Indicator

The most reliable indicator of neurological status is the level of consciousness.

Herpes Zoster

Caused by the Varicella-Zoster virus (VZV).

Amyotrophic Lateral Sclerosis (ALS)

Average survival is 3-5 years.
Symptoms include difficulty swallowing, breathing issues, inability to communicate, constipation, with overall decline.

Immediate Burn Patient Care

Prioritize ABCs and initiate fluid replacement due to hypovolemia from fluid loss.

Cushing's Triad

Indicators of increased intracranial pressure include bradycardia, elevated systolic blood pressure with wide pulse pressure, and irregular respirations.

Ampule Medication Withdrawal

Use a filter needle; avoid contact of the filter needle with the ampule edge to prevent contamination.

Receptive Aphasia

Defined as the inability to understand spoken or written language.

Enoxaparin Injection Site

Administer in the right or left abdomen, 2 inches from the belly button.

Abdominal Wound Healing

Implement docusate for stool softening, manage nausea, use a pillow for coughing, employ an abdominal binder, and monitor blood sugar levels.

Isotonic Fluids

Include Normal Saline (0.9% NaCl) and Lactated Ringer’s (LR), utilized for fluid resuscitation in hypovolemic shock and dehydration.

Blind Person Walking Technique

Guide slightly ahead and to the side, allowing the individual to touch your elbow.

Pediatric Medication Measurement

Use an oral syringe for accurate dosing in children.

Dressing a Stroke Patient

Dress the affected side first to accommodate mobility limitations.

Systemic Lupus Erythematosus (SLE) Symptoms

Present elevated ESR and positive ANA test results, with potential decreased WBC count, thrombocytopenia, and anemia.
Monitor for kidney damage.

Halo Device Care

Clean pin sites with sterile solution, keep the vest liner dry with a cool blow dryer, and place foam under pressure points.

Lithotripsy Care

Encourage increased fluid intake, expect minor bruising, and report any signs of infection post-procedure.

Sprain Treatment

Follow RICE protocol (Rest, Ice, Compression, Elevation) and introduce rehabilitation once healed.

Pursed Lip Breathing Technique

Inhale for 2 seconds through the nose; exhale for 4 seconds through pursed lips.

Hip Fracture Indicators

Symptoms include external rotation, muscle spasms, site bruising, limb shortening, and pain with weight bearing.

Cephalohematoma

Considered a normal condition, characterized by a collection of blood between skull bone and periosteum.

Physiological Jaundice of the Newborn

Develops after 24 hours, often due to dehydration or insufficient breastfeeding.

Magnesium Sulfate

Used as a tocolytic in preeclampsia, halting contractions, while monitoring for hypermagnesemia.

Oxytocin (Pitocin)

Can lead to uterine hyperstimulation with contractions lasting over 90 seconds or occurring less than 2 minutes apart.

Betamethasone

Administered for fetal lung maturity in preterm labor, given as two IM injections 24 hours apart.

Survanta (Synthetic Surfactant)

Administered to neonates via transtracheal route immediately following birth.

Normal Pregnancy Weight Gain

Typical total gain is about 28 lbs, with a variability of +/- 3 lbs.

Methergine (Ergometrine)

An oxytocic that can raise maternal blood pressure, used to enhance labor strength.

Terbutaline in Pregnancy

Acts as a tocolytic, may cause maternal tachycardia while relaxing the uterus to prevent preterm labor.

Pathological Jaundice

Occurs before 24 hours of life, signifying possible early hemolysis.

Caput Succedaneum

A symmetrical bruise crossing sutures, recognized as a normal condition.

Erythema Toxicum Neonatorum

Benign, papular rash commonly seen in newborns.

Safe Psych Medications in Pregnancy

Haldol is the only tranquilizer indicated for use during pregnancy.

Probable Signs of Pregnancy

Chadwick’s, Godel’s, and Hegar’s signs denote early pregnancy indicators, characterized by changes in the vagina, cervix, and uterus, respectively.

Latent Phase of Labor

Dilation ranges from 0-4 cm with contractions occurring every 5-30 minutes lasting 15-30 seconds, generally mild in intensity.

Pain Medications in Labor

Avoid administering pain medication just before delivery due to potential effects on the infant; provide during contractions for safety.

Prolapsed Cord Management

Push and position effectively to manage complications.

Variable Decelerations

Indicates a critical situation with slow fetal heart rate due to cord prolapse; requires intervention to reposition.

Placental Structure

Consists of 3 vessels: 2 arteries and 1 vein; ensure all vessels are delivered to prevent maternal hemorrhage.

Baby Identification Protocol

An ID band is required for every newborn before leaving the delivery area.

Addressing Uncertainty in OB Questions

Assess fetal heart rate (FHR) for guidance in decision-making.

FHR Patterns

"Veal Chop" mnemonic:
- Variable decelerations indicate cord compression.
- Early decelerations indicate head compression.
- Accelerations are normal.
- Late decelerations indicate placental insufficiency.

FHR Tracing Guidelines

If FHR tracing begins with "L," assess and perform LION (Lie, Oxygen, IV fluids, Notify physician). Document normal tracings; respond aggressively to variable decelerations.

Late Decelerations Assessment

Recognized as bad; follow LION protocol immediately.

FHR Variability

High baseline variability (6-25 points) is indicative of well-being; ensure documentation.
Low baseline variability shows stable FHR, necessitating intervention (LION).

High and Low FHR Values

High FHR (>160) is usually not concerning unless linked to maternal fever.
Low FHR requires prompt evaluation and response.

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Description

Test your knowledge on various nursing assessments including BPH, patient positioning, and septic shock symptoms. This quiz includes flashcards designed to reinforce essential information for nursing practice. Ensure you're prepared for clinical scenarios with these key concepts.