Patient Assessment and Evaluation Flashcards
7 cards from real TRIVIUM practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Patient Assessment and Evaluation flashcards as text
When taking an apical pulse, the nurse aide places the stethoscope at which anatomical landmark?
Answer: Left midclavicular line, 5th intercostal space
The apical pulse is heard at the point of maximal impulse, located at the left midclavicular line at the 5th intercostal space.
A patient is assessed using the PAINAD scale. This scale is specifically designed for:
Answer: Patients with advanced dementia who cannot self-report pain
The PAINAD scale assesses pain in patients with advanced dementia using behavioral indicators like breathing, vocalizations, and body language.
Which assessment finding would be considered a normal variant in an elderly patient?
Answer: Decreased skin turgor due to natural loss of elasticity
Decreased skin turgor is a normal age-related change due to loss of subcutaneous fat and skin elasticity.
During a patient intake assessment, the nurse aide should report which of the following findings related to medication?
Answer: The patient takes warfarin (a blood thinner) daily
Warfarin is a high-alert medication that affects blood clotting and must be accurately communicated during all assessments.
A patient's Glasgow Coma Scale (GCS) score is 15. What does this indicate?
Answer: The patient is fully conscious with normal neurological function
A GCS score of 15 is the maximum, indicating the patient is fully alert, oriented, and following commands normally.
When documenting a patient's pain assessment, which entry meets documentation standards?
Answer: Patient c/o chest pain 6/10, sharp, onset 30 min ago, not relieved by position change. RN notified.
Complete pain documentation includes location, intensity, quality, onset, aggravating/relieving factors, and actions taken.
A patient who was previously able to walk with a cane is now unable to bear weight and reports hip pain after a fall. The priority nursing assessment concern is:
Answer: Possible hip fracture requiring immediate medical evaluation
Inability to bear weight with hip pain after a fall is highly suspicious for hip fracture, requiring urgent medical assessment.