Patient Assessment Flashcards

Which systematic framework is commonly used by NZ nurses to communicate patient deterioration to the medical team?

Answer: SBAR (Situation, Background, Assessment, Recommendation)

SBAR (or ISBAR including Identify) is the recommended communication tool for escalating patient deterioration in NZ healthcare settings, providing a structured, efficient handover that reduces communication failures.

Which vital sign parameter, when added to the NEWS2 (National Early Warning Score 2), specifically addresses sepsis risk?

Answer: New confusion or altered mental state

The NEWS2 scoring system includes new confusion/altered consciousness (scored as 3 — the highest possible for a single parameter) as an acute indicator of potential sepsis, organ dysfunction, or neurological deterioration.

A patient's SpO2 drops to 90% on room air. What is the most appropriate initial nursing action?

Answer: Apply supplemental oxygen and escalate to the medical team using SBAR/ISBAR

An SpO2 of 90% is below the normal range (95–100%) and indicates hypoxaemia. The nurse should apply supplemental oxygen, reassess, and escalate to the medical team promptly. Oxygen therapy should be titrated to target saturation.

When completing a pain assessment for an adult patient who is unable to self-report pain, which tool is most appropriate?

Answer: Behavioural Pain Scale (BPS) or Critical Care Pain Observation Tool (CPOT)

When patients cannot self-report (e.g., intubated, cognitively impaired), observational tools like the BPS or CPOT assess behavioural indicators of pain (facial expression, body movement, ventilator compliance). Self-report tools require the patient to communicate a number or point.

Which of the following is the correct interpretation of a 12-lead ECG finding: P waves present, regular rhythm, rate 90 bpm, PR interval 0.14 s, QRS 0.08 s?

Answer: Normal sinus rhythm

This ECG describes normal sinus rhythm: P waves present before each QRS, regular rhythm, rate 60–100 bpm, normal PR interval (0.12–0.20 s), and normal QRS duration (<0.12 s). All parameters are within normal limits.

A patient is admitted after a fall. On assessment, the nurse notices bruising at different stages of healing and a pattern inconsistent with the reported mechanism. What should the nurse do?

Answer: Document the findings thoroughly, report to the nurse in charge, and follow the organisation's safeguarding or elder abuse protocol

Inconsistent injuries with multi-stage bruising raise safeguarding concerns. The nurse must document accurately, escalate to the senior nurse, and follow the organisation's safeguarding protocol. In NZ, elder abuse and family violence require a structured response.