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

A sudden 5-pound weight gain can indicate fluid retention, which may signal cardiac or kidney problems and must be reported.

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

The FACES pain scale uses facial expressions to assess pain and is most helpful for children or those with limited verbal ability.

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

Pitting edema occurs when excess fluid accumulates in tissue and leaves an indentation when pressed.

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

Unexplained bruises must be documented and reported to the nurse to rule out falls, abuse, or bleeding disorders.

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

A blood pressure of 90/60 mmHg is hypotensive and can indicate inadequate perfusion, requiring prompt nursing evaluation.

(INACE) Illinois Nurse Assistant Competency Exam Practice Test