NMBI Patient Assessment 2 — Questions and Answers
Question 1: A patient develops sudden onset chest pain, diaphoresis, and shortness of breath. What is the nurse's immediate action?
- Call for help, perform an ABCDE assessment, apply oxygen if needed, obtain IV access, and prepare for ECG and urgent medical review (Correct answer)
- Reassure the patient and document the symptoms
- Give PRN analgesia and continue monitoring
- Wait for the next scheduled medical round
Correct answer: Call for help, perform an ABCDE assessment, apply oxygen if needed, obtain IV access, and prepare for ECG and urgent medical review
This presentation is consistent with acute coronary syndrome (heart attack). Immediate ABCDE assessment, urgent medical team activation, oxygen, IV access, and ECG are all time-critical.
Question 2: What does a Braden Scale score of 12 indicate?
- High risk of pressure ulcer development (Correct answer)
- No risk of pressure ulcer
- Low risk of pressure ulcer
- Moderate risk with no intervention needed
Correct answer: High risk of pressure ulcer development
The Braden Scale scores 6–23. A score of 12 is in the 'high risk' category (scores ≤12 = high risk, 13–14 = moderate risk). Preventive interventions such as repositioning and specialist mattress are required.
Question 3: When assessing a patient for deep vein thrombosis (DVT), which clinical sign might be present?
- Unilateral calf swelling, warmth, and tenderness (Correct answer)
- Bilateral leg oedema
- Reduced sensation in both legs
- Cold, pale extremities
Correct answer: Unilateral calf swelling, warmth, and tenderness
DVT classically presents with unilateral calf swelling, warmth, redness, and tenderness. Bilateral symptoms and other findings suggest different pathology (e.g., cardiac failure for bilateral oedema).
Question 4: What does a urinary output of less than 0.5ml/kg/hour for two consecutive hours suggest?
- Oliguria, possibly indicating acute kidney injury or inadequate fluid intake (Correct answer)
- Normal renal function
- Polyuria requiring fluid restriction
- Dehydration that does not need urgent review
Correct answer: Oliguria, possibly indicating acute kidney injury or inadequate fluid intake
Oliguria (low urine output) is defined as <0.5ml/kg/hour. Persistent oliguria may indicate acute kidney injury (AKI), inadequate fluid resuscitation, or haemodynamic compromise and requires urgent escalation.
Question 5: What is the MUST tool used to assess?
- Nutritional risk / malnutrition risk (Correct answer)
- Pressure ulcer risk
- Fall risk
- Mental health status
Correct answer: Nutritional risk / malnutrition risk
MUST (Malnutrition Universal Screening Tool) assesses nutritional risk based on BMI, unplanned weight loss, and acute illness. Scores guide referral to dietetics and nutritional intervention.
Question 6: When taking a patient history, what does the mnemonic 'SAMPLE' stand for?
- Symptoms, Allergies, Medications, Past medical history, Last oral intake, Events leading up to presentation (Correct answer)
- Severity, Allergies, Medicines, Problems, Location, Examination
- Symptoms, Age, Medical history, Pain, Location, Events
- Severity, Allergies, Medications, Past surgery, Last meal, Events
Correct answer: Symptoms, Allergies, Medications, Past medical history, Last oral intake, Events leading up to presentation
SAMPLE is a structured history-taking tool: Symptoms, Allergies, Medications, Past medical history, Last oral intake (especially pre-procedure), and Events. It ensures no key history is missed.
NMBI Patient Assessment 2
A patient develops sudden onset chest pain, diaphoresis, and shortness of breath.
What is the nurse's immediate action?