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NSE 203 Final Exam With Verified Answers
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NSE 203 Final Exam WithVerified Answers
clinical deterioration not promptly recognized can - Answer increase pt morbidity &
mortality
barrier to recognizing & responding to clinical deterioration stems from ... - Answer
practice variations among HCP
consequences of not recognizing patient deterioration - Answer increased mortality,
resuscitation, implementation of higher lvl of care & prolonged hospital admission
What is part of an ABCDE assessment? - Answer 1) airway
2) breathing
3) circulation
4) disability
5) environment & exposure
priority things to look for in pt airway? - Answer - any blocked or threatened airways
- pt LOC
- abnormal respiratory assessment findings (ex; stridor)
if you suspect neurological trauma when assessing airway you ... - Answer start w/ triple
airway maneuver!!
Triple airway manoeuvre - Answer chin lift, jaw thrust, patient oxygen
what does vital sign instability & visible patient deterioration tend to occur? - Answer in
most pts from 6-24 hrs before cardiac arrest
clinical deterioration - Answer patient compromising *hemodynamic stability, marked by
physiological decompensation* accompanied by subjective or objective findings.
dynamic state - Answer variations in physiological parameters
decompensation - Answer inability to maintain homeostatic fxn physiologically or
psychologically
what are indicators of clinical deterioration - Answer - sudden and/or unstable changes
in vital signs (RR, BP, HR, O2)
- for expert nurses, their intuition helps them determine if a patient looks right
,- skin color changes
- decreased LOC
assessments to recognize deterioration - Answer ABCDE
NEWS2
FAST
signs during primary survey that are *significantly associated w/ death* ... - Answer -
partial airway obstruction
- poor peripheral circulation
- greater than expected drain fluid loss
- decreased UO
- decreased GCS
- abnormal RR
- new pain
- low O2sat & low BP
- alteration in mentation
NEWS2 aka - Answer national early warning score
purpose of NEWS2 - Answer - improve detection of & response to clinical deterioration
in patients w/ acute illness
- provide *standardized approach* to care of deteriorating patient
- clear communication
- identify a *score* for urgent clinical response
what does the NEWS2 score mean? - Answer *a high NEWS2 score* identifies a sick
patient who is deteriorating & requires *urgent clinical review*
what does NEWS2 score evaluate? - Answer - RR
- O2 Sat
- systolic BP
- HR
- LOC or new confusion
, - temp
what to do if NEWS score is greater or equal to 3 - Answer discuss w/ duty nurse/senior
colleague, & complete a *sepsis screen for signs of infection*
what to do if NEWS score is greater or equal to 6 - Answer immediate discussion w/ ACT
advanced practitioner or ACT dr
NEW score 0-4, clinical risk & response - Answer low risk, ward-based response
NEW score of 3, clinical risk & response - Answer low-medium, urgent ward-based
response
NEW score of 5-6, clinical risk & response - Answer medium, key threshold for urgent
response
NEW score of 7+, clinical risk & response - Answer high risk, urgent or *emergency
response*
what is FAST used for? - Answer to identify most common signs of stroke (ischemic,
hemorrhagic or mini)
if a patient shows a FAST symptom ... - Answer emergency action is required . Call 911
(outside), or stroke team (inside)
what does FAST stand for? - Answer F(acial dropping)
A(rm weakness)
S(peech slurred/jumbled)
T(ime to call 911 or help right away)
interpersonal violence includes - Answer - intimate partner violence
- sexual violence
- child maltreatment/abuse
- elder abuse
- human trafficking
what are the health effects of IPV violence? - Answer - direct injury
- chronic health problems (chronic pain, neurologic, GI, gynecologic, hypertension)
- mental health problems (depression, anxiety, self-esteem, suicide)
- behavioural consequences (substance abuse, eating/sleep disorders, unsafe sexual
behaviour, smoking, physical inactivity)
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