INACE Patient Assessment and Evaluation 4

Question 1

A nursing assistant is measuring a patient's weight and notices a gain of 5 pounds since yesterday. This should be:

Accepted Answer

Reported to the nurse as it may indicate fluid retention

Answer

Ignored since daily fluctuations are normal

Answer

Attributed to the patient eating more and not documented

Answer

Rechecked in one week before reporting

Question 2

When using the FACES pain scale, which patient would this tool be MOST appropriate for?

Accepted Answer

A child or patient who cannot verbally communicate a numeric rating

Answer

An alert adult patient who can verbally rate pain

Answer

A patient who is unconscious

Answer

A patient with no reported pain

Question 3

A nursing assistant observes a patient's ankle is swollen and pitting. What does pitting edema indicate?

Accepted Answer

Fluid accumulating in the tissue

Answer

Normal variation in ankle size

Answer

Bone deformity from aging

Answer

A healed injury with residual scarring

Question 4

During care, a nursing assistant notices a new bruise on a patient's arm that the patient cannot explain. The appropriate action is to:

Accepted Answer

Document it and report it to the nurse, as it may indicate abuse or a fall

Answer

Apply ice to the bruise and continue care

Answer

Assume the patient bumped themselves and ignore it

Answer

Wait to see if more bruises appear before reporting

Question 5

A patient's blood pressure reading is 90/60 mmHg. This reading is considered:

Accepted Answer

Hypotensive and should be reported to the nurse

Answer

Normal for an adult

Answer

Hypertensive and requires immediate intervention

Answer

Within acceptable range and needs no follow-up

Question 6

Which behavior change in a dementia patient should be reported to the nurse?

Accepted Answer

Patient suddenly becomes aggressive and combative without apparent cause

Answer

Patient is calm and cooperative during morning care

Answer

Patient enjoys watching television in the common area

Answer

Patient asks to call a family member

Question 7

When observing a patient's skin during bathing, which finding indicates the BEST skin integrity?

Accepted Answer

Skin is intact, warm, and moist with good turgor

Answer

Skin is dry, flaky, and tented when pinched

Answer

Skin has open areas over both heels

Answer

Skin is mottled and bluish over the feet