Trivium Patient Assessment and Evaluation 3 — Questions and Answers
Question 1: A patient with dementia is pacing and repeatedly saying 'I need to go home.' Using a behavioral pain assessment approach, this behavior most likely indicates:
- The patient is ready for discharge
- The patient may be experiencing pain, discomfort, or anxiety (Correct answer)
- The patient is being non-compliant
- The patient needs a psychiatric evaluation
Correct answer: The patient may be experiencing pain, discomfort, or anxiety
In patients who cannot verbalize pain clearly, behavioral cues like agitation and repetitive statements may signal pain or distress.
Question 2: Which vital sign pattern would indicate a patient may be going into septic shock?
- BP 140/90, HR 65, Temp 98.6°F
- BP 88/52, HR 118, Temp 103.2°F (Correct answer)
- BP 120/80, HR 72, Temp 99.1°F
- BP 130/85, HR 80, Temp 97.8°F
Correct answer: BP 88/52, HR 118, Temp 103.2°F
Low blood pressure, rapid heart rate, and high fever together suggest septic shock and require emergency intervention.
Question 3: A nurse aide is assessing a patient's level of consciousness. The patient opens eyes to voice, speaks in confused sentences, and localizes pain. Using the AVPU scale, how is this patient classified?
- Alert
- Voice responsive (Correct answer)
- Pain responsive
- Unresponsive
Correct answer: Voice responsive
The patient responds to voice stimulation, placing them in the 'Voice' category of the AVPU scale.
Question 4: During a nutritional assessment, which observation most warrants reporting to the nurse?
- Patient ate 75% of lunch
- Patient has consumed less than 25% of meals for three days (Correct answer)
- Patient prefers soup over solid foods
- Patient drinks coffee with breakfast
Correct answer: Patient has consumed less than 25% of meals for three days
Consistently poor intake over multiple days indicates a nutritional risk that requires nursing and dietary follow-up.
Question 5: Which assessment technique is used to evaluate the equality and strength of pedal pulses?
- Auscultation of the lower legs
- Palpation of the dorsal foot arteries bilaterally (Correct answer)
- Percussion of the lower extremities
- Inspection of nail beds only
Correct answer: Palpation of the dorsal foot arteries bilaterally
Pedal pulses are assessed by palpating the dorsalis pedis and posterior tibial arteries and comparing both sides.
Question 6: A patient who was alert and conversational this morning is now drowsy and only mumbles brief responses. This change most likely indicates:
- The patient is simply tired from activities
- A significant neurological or systemic change requiring immediate reporting (Correct answer)
- Normal afternoon fatigue in elderly patients
- The patient needs a hearing evaluation
Correct answer: A significant neurological or systemic change requiring immediate reporting
Acute changes in mental status are a red flag for serious conditions such as stroke, infection, or metabolic crisis.
Question 7: When assessing a wound during dressing change, which finding requires immediate reporting?
- A small amount of clear serous drainage
- Pink granulation tissue at the wound base
- Sudden increase in purulent, foul-smelling drainage (Correct answer)
- Wound edges that are well-approximated
Correct answer: Sudden increase in purulent, foul-smelling drainage
Sudden increase in purulent, malodorous drainage suggests infection and requires prompt nursing assessment.
Trivium Patient Assessment and Evaluation 3
A patient with dementia is pacing and repeatedly saying 'I need to go home.' Using a behavioral pain assessment approach, this behavior most likely indicates: