Nursing Assessment Quiz

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.