Patient Assessment and Evaluation Flashcards

A patient's skin shows redness over a bony prominence that does not disappear when pressure is relieved. This is classified as a:

Answer: Stage 1 pressure injury

Non-blanchable redness over a bony prominence with intact skin is classified as a Stage 1 pressure injury.

When performing a head-to-toe observation, which area should the nursing assistant examine for signs of jaundice?

Answer: Sclera of the eyes and skin

Jaundice causes yellowing of the skin and the whites of the eyes (sclera), making these the primary areas to assess.

A nursing assistant notices a patient has not eaten 75% of their meal for the past three days. The BEST response is to:

Answer: Encourage the patient to eat more and document intake accurately

Documenting intake accurately and encouraging the patient alerts the nurse to potential nutritional concerns.

Which change in a resident's mental status should be reported to the nurse immediately?

Answer: Resident is suddenly confused and does not recognize family members

Sudden onset confusion and failure to recognize family may indicate stroke, infection, or other acute conditions requiring immediate attention.

When assessing capillary refill time, the nursing assistant presses on a patient's fingernail and releases. Normal color should return within:

Answer: 2 seconds

Normal capillary refill time is less than 2 seconds; longer times may indicate poor circulation.

A patient rates their pain as 8 out of 10 on the pain scale. The nursing assistant's FIRST action should be:

Answer: Report the pain level to the nurse promptly

A pain score of 8/10 is severe and must be reported to the nurse immediately so appropriate interventions can be ordered.

Which observation about a wound should be documented and reported to the nurse?

Answer: Surrounding skin is warm, red, and swollen with purulent discharge

Warmth, redness, swelling, and purulent discharge are signs of infection requiring immediate nursing evaluation.