INACE Patient Assessment and Evaluation 2

Question 1

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

Accepted Answer

Report these findings to the nurse immediately

Answer

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

Question 2

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

Accepted Answer

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

Answer

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

Question 3

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

Accepted Answer

Urine appears dark amber and has a strong odor

Answer

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

Question 4

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

Accepted Answer

Orthostatic hypotension

Answer

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

Question 5

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

Accepted Answer

Patient responds only to pain

Answer

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

(INACE) Illinois Nurse Assistant Competency Exam Practice Test