Patient Assessment and Evaluation Flashcards

A nursing assistant is measuring a patient's weight and notices a gain of 5 pounds since yesterday. This should be:

Answer: Reported to the nurse as it may indicate fluid retention

A sudden 5-pound weight gain can indicate fluid retention, which may signal cardiac or kidney problems and must be reported.

When using the FACES pain scale, which patient would this tool be MOST appropriate for?

Answer: A child or patient who cannot verbally communicate a numeric rating

The FACES pain scale uses facial expressions to assess pain and is most helpful for children or those with limited verbal ability.

A nursing assistant observes a patient's ankle is swollen and pitting. What does pitting edema indicate?

Answer: Fluid accumulating in the tissue

Pitting edema occurs when excess fluid accumulates in tissue and leaves an indentation when pressed.

During care, a nursing assistant notices a new bruise on a patient's arm that the patient cannot explain. The appropriate action is to:

Answer: Document it and report it to the nurse, as it may indicate abuse or a fall

Unexplained bruises must be documented and reported to the nurse to rule out falls, abuse, or bleeding disorders.

A patient's blood pressure reading is 90/60 mmHg. This reading is considered:

Answer: Hypotensive and should be reported to the nurse

A blood pressure of 90/60 mmHg is hypotensive and can indicate inadequate perfusion, requiring prompt nursing evaluation.

Which behavior change in a dementia patient should be reported to the nurse?

Answer: Patient suddenly becomes aggressive and combative without apparent cause

Sudden unexplained aggression in a dementia patient can indicate pain, infection, or another medical issue requiring assessment.

When observing a patient's skin during bathing, which finding indicates the BEST skin integrity?

Answer: Skin is intact, warm, and moist with good turgor

Intact, warm, moist skin with good turgor indicates healthy skin without signs of breakdown or dehydration.