NMBI Patient Assessment 2

Question 1

A patient develops sudden onset chest pain, diaphoresis, and shortness of breath. What is the nurse's immediate action?

Accepted Answer

Call for help, perform an ABCDE assessment, apply oxygen if needed, obtain IV access, and prepare for ECG and urgent medical review

Answer

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?

Accepted Answer

High risk of pressure ulcer development

Answer

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?

Accepted Answer

Unilateral calf swelling, warmth, and tenderness

Answer

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?

Accepted Answer

Oliguria, possibly indicating acute kidney injury or inadequate fluid intake

Answer

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?

Accepted Answer

Nutritional risk / malnutrition risk

Answer

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.

NMBI Practice Test

NMBI Practice Test

NMBI Patient Assessment 2