Patient Assessment and Evaluation Flashcards

A nursing assistant notices a resident's skin is pale, cool, and clammy. What should be done first?

Answer: Report these findings to the nurse immediately

Pale, cool, clammy skin can indicate shock or circulatory problems and must be reported to the nurse immediately.

When counting a patient's pulse, the nursing assistant notes it is irregular. What is the correct action?

Answer: Count for a full 60 seconds and report the irregularity to the nurse

An irregular pulse should be counted for a full 60 seconds and the irregularity reported to the nurse for further evaluation.

Which observation about urine output should be reported to the nurse?

Answer: Urine appears dark amber and has a strong odor

Dark amber urine with a strong odor may indicate dehydration or infection and must be reported to the nurse.

A resident reports feeling dizzy when standing up from a chair. This symptom is MOST associated with:

Answer: Orthostatic hypotension

Dizziness upon standing is a classic sign of orthostatic hypotension, a drop in blood pressure when changing positions.

When assessing a patient's level of consciousness, which response indicates the LOWEST level of responsiveness?

Answer: Patient responds only to pain

Responding only to painful stimuli indicates a severely decreased level of consciousness.

A nursing assistant is observing a patient's respirations. Which finding requires immediate reporting?

Answer: Respirations of 8 per minute with periods of no breathing

A rate of 8 breaths per minute with apnea periods is dangerously low and requires immediate reporting.

Which action BEST helps a nursing assistant accurately measure a patient's blood pressure?

Answer: Allow the patient to rest quietly for at least 5 minutes before measurement

Allowing the patient to rest 5 minutes before measurement ensures a more accurate baseline blood pressure reading.