INACE Patient Assessment and Evaluation 3

Question 1

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

Accepted Answer

Stage 1 pressure injury

Answer

Stage 2 pressure injury

Answer

Stage 3 pressure injury

Answer

Deep tissue injury

Question 2

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

Accepted Answer

Sclera of the eyes and skin

Answer

Fingernails and toenails

Answer

Inside of the mouth only

Answer

Palms of the hands

Question 3

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

Accepted Answer

Encourage the patient to eat more and document intake accurately

Answer

Assume the patient is not hungry and remove the tray

Answer

Tell the patient they must eat everything

Answer

Offer an alternative food without documenting

Question 4

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

Accepted Answer

Resident is suddenly confused and does not recognize family members

Answer

Resident is slightly sleepy after lunch

Answer

Resident is quiet and reading a book

Answer

Resident takes longer than usual to answer questions

Question 5

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

Accepted Answer

2 seconds

Answer

10 seconds

Answer

5 seconds

Answer

15 seconds

Question 6

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

Accepted Answer

Report the pain level to the nurse promptly

Answer

Administer pain medication from the supply cart

Answer

Reposition the patient and then reassess in four hours

Answer

Tell the patient to relax and breathe deeply

Question 7

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

Accepted Answer

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

Answer

Wound edges are approximated and healing

Answer

No drainage is present

Answer

Wound is dry and covered with an intact dressing