Patient Assessment and Evaluation Flashcards

A nursing assistant is asked to observe a patient's stool. Which observation is MOST important to report?

Answer: Stool that is black, tarry, and has a foul odor

Black, tarry stool (melena) can indicate upper gastrointestinal bleeding and must be reported to the nurse immediately.

A patient complains of chest pain and shortness of breath. The nursing assistant should:

Answer: Call for the nurse immediately and stay with the patient

Chest pain with shortness of breath can indicate a cardiac or pulmonary emergency; the nurse must be called immediately.

Which finding during a neurological observation should be reported to the nurse?

Answer: Patient's right arm is weaker than the left arm

Unequal arm strength can indicate a neurological problem such as a stroke and requires immediate reporting.

A nursing assistant measures a patient's blood glucose using a glucometer and gets a reading of 48 mg/dL. The correct action is to:

Answer: Give the patient orange juice and report to the nurse immediately

A blood glucose of 48 mg/dL is dangerously low hypoglycemia; providing a fast-acting sugar and notifying the nurse immediately is critical.

When assessing a patient for dehydration, which finding is MOST consistent with this condition?

Answer: Dry mouth, sunken eyes, and dark concentrated urine

Dry mouth, sunken eyes, and dark urine are classic signs of dehydration indicating fluid deficit.

A nursing assistant notices a patient's drainage tube is putting out less fluid than usual and the patient's abdomen appears more distended. This should be:

Answer: Reported to the nurse immediately as it may indicate a blockage

Decreased tube output combined with abdominal distension may indicate a blocked tube, requiring immediate nursing evaluation.

Which question is MOST appropriate for a nursing assistant to ask when using a standardized pain assessment?

Answer: 'On a scale of 0 to 10, how would you rate your pain right now?'

Using the 0–10 numeric rating scale is a standardized, objective way to assess and document pain intensity.