Patient Assessment Flashcards

Which assessment tool is recommended in NZ for identifying patients at risk of pressure injuries?

Answer: Braden Scale

The Braden Scale is the most widely validated and commonly used pressure injury risk assessment tool internationally and in NZ, assessing sensory perception, moisture, activity, mobility, nutrition, and friction/shear.

A nurse assesses a patient 4 hours post-appendicectomy. The patient has a respiratory rate of 24/min, temperature 38.8°C, heart rate 112 bpm, and is confused. What does this most likely represent?

Answer: Systemic Inflammatory Response Syndrome (SIRS) / early sepsis — escalate immediately

Two or more SIRS criteria (RR >20, temp >38 or 90, WBC abnormal) with suspected infection (post-operative setting) constitutes suspected sepsis. Confusion adds neurological deterioration. This requires immediate escalation under the sepsis six pathway.

When performing a neurological assessment using the Glasgow Coma Scale, what is the maximum total score?

Answer: 15

The GCS assesses three domains: Eye opening (1–4), Verbal response (1–5), and Motor response (1–6). Maximum total = 4 + 5 + 6 = 15 (fully conscious). Minimum = 3 (deep coma or death).

Which of the following is most consistent with an early sign of respiratory compromise in an adult patient?

Answer: Increasing respiratory rate (tachypnoea)

Tachypnoea (increased respiratory rate) is typically the earliest sign of respiratory compromise, preceding cyanosis, hypoxaemia on pulse oximetry, and haemodynamic changes. It reflects the body's compensatory attempt to maintain oxygenation.

When assessing fluid balance in a post-operative patient, which of the following is the most accurate method?

Answer: Strict hourly fluid balance chart recording all intake (IV, oral, feeds) and output (urine, drains, NG, stool, vomit)

Accurate fluid balance requires documenting all measured inputs (IV fluids, oral intake, enteral feeds) and outputs (urine, wound drains, nasogastric aspirate, vomit, stool) hourly in the acute post-operative period.

A nurse performs a head-to-toe assessment and notices a new sacral pressure injury with intact skin but non-blanchable erythema. Which category/stage does this represent?

Answer: Category 1 pressure injury

Category 1 pressure injury: intact skin with non-blanchable erythema. The skin is not broken but redness does not fade with pressure relief, indicating localised damage. It requires immediate pressure relief and management to prevent progression.