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

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?

Accepted Answer

Sclera of the eyes and skin

Answer

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:

Accepted Answer

Encourage the patient to eat more and document intake accurately

Answer

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?

Accepted Answer

Resident is suddenly confused and does not recognize family members

Answer

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:

Accepted Answer

2 seconds

Answer

Normal capillary refill time is less than 2 seconds; longer times may indicate poor circulation.

(INACE) Illinois Nurse Assistant Competency Exam Practice Test