INACE Patient Assessment and Evaluation 3 — Questions and Answers
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:
- Stage 1 pressure injury (Correct answer)
- Stage 2 pressure injury
- Stage 3 pressure injury
- Deep tissue injury
Correct answer: Stage 1 pressure injury
Non-blanchable redness over a bony prominence with intact skin is classified as a Stage 1 pressure injury.
Question 2: When performing a head-to-toe observation, which area should the nursing assistant examine for signs of jaundice?
- Fingernails and toenails
- Sclera of the eyes and skin (Correct answer)
- Inside of the mouth only
- Palms of the hands
Correct 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.
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:
- Assume the patient is not hungry and remove the tray
- Encourage the patient to eat more and document intake accurately (Correct answer)
- Tell the patient they must eat everything
- Offer an alternative food without documenting
Correct 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.
Question 4: Which change in a resident's mental status should be reported to the nurse immediately?
- Resident is slightly sleepy after lunch
- Resident is suddenly confused and does not recognize family members (Correct answer)
- Resident is quiet and reading a book
- Resident takes longer than usual to answer questions
Correct 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.
Question 5: When assessing capillary refill time, the nursing assistant presses on a patient's fingernail and releases. Normal color should return within:
- 10 seconds
- 5 seconds
- 2 seconds (Correct answer)
- 15 seconds
Correct answer: 2 seconds
Normal capillary refill time is less than 2 seconds; longer times may indicate poor circulation.
Question 6: A patient rates their pain as 8 out of 10 on the pain scale. The nursing assistant's FIRST action should be:
- Administer pain medication from the supply cart
- Reposition the patient and then reassess in four hours
- Report the pain level to the nurse promptly (Correct answer)
- Tell the patient to relax and breathe deeply
Correct 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.
Question 7: Which observation about a wound should be documented and reported to the nurse?
- Wound edges are approximated and healing
- No drainage is present
- Surrounding skin is warm, red, and swollen with purulent discharge (Correct answer)
- Wound is dry and covered with an intact dressing
Correct 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.
INACE Patient Assessment and Evaluation 3
A patient's skin shows redness over a bony prominence that does not disappear when pressure is relieved.
This is classified as a: