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Patient Assessment and Diagnosis Flashcards

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  1. A pediatric patient presents with a barking cough, inspiratory stridor, and low-grade fever. The MOST likely diagnosis is:

    Answer: Croup (laryngotracheobronchitis)

    A barking 'seal-like' cough, stridor, and low-grade fever in a toddler are hallmark findings of viral croup.

  2. Which assessment finding is MOST indicative of increased intracranial pressure in an adult?

    Answer: Bradycardia, hypertension, and irregular respirations

    Cushing's triad — bradycardia, hypertension, and irregular respirations — is a late and ominous sign of rising ICP.

  3. A patient presents with inspiratory crackles, JVD, S3 gallop, and bilateral pitting edema. These findings are MOST consistent with:

    Answer: Acute decompensated heart failure

    Crackles, JVD, an S3 gallop, and bilateral edema together indicate acute decompensated heart failure with volume overload.

  4. During assessment of an abdominal aortic aneurysm (AAA), the nurse palpates a pulsatile midline mass. Which associated finding would suggest rupture?

    Answer: Sudden severe pain radiating to the back with hypotension

    Sudden severe abdominal or back pain with hemodynamic instability in a patient with a known AAA strongly suggests rupture.

  5. A trauma patient is GCS 8. What is the PRIORITY nursing action?

    Answer: Prepare for definitive airway management

    A GCS of 8 or less indicates inability to protect the airway, making definitive airway management the immediate priority.

  6. When assessing a burn patient, which formula is used to estimate the percentage of total body surface area (TBSA) burned in adults?

    Answer: Rule of Nines

    The Rule of Nines divides the adult body into regions each representing 9% (or multiples of 9%) to estimate TBSA burned.

  7. A patient with diabetes presents with Kussmaul respirations, fruity breath odor, and altered mental status. The nurse should anticipate which diagnosis?

    Answer: Diabetic ketoacidosis (DKA)

    Kussmaul respirations (deep, rapid) and fruity breath from acetone are compensatory signs of metabolic acidosis in DKA.

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Patient Assessment and Diagnosis Flashcards — BCEN Study Cards with Answers