Trivium Patient Assessment and Evaluation 3

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:

Accepted Answer

The patient may be experiencing pain, discomfort, or anxiety

Answer

The patient is ready for discharge

Answer

The patient is being non-compliant

Answer

The patient needs a psychiatric evaluation

Question 2

Which vital sign pattern would indicate a patient may be going into septic shock?

Accepted Answer

BP 88/52, HR 118, Temp 103.2°F

Answer

BP 140/90, HR 65, Temp 98.6°F

Answer

BP 120/80, HR 72, Temp 99.1°F

Answer

BP 130/85, HR 80, Temp 97.8°F

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?

Accepted Answer

Voice responsive

Answer

Alert

Answer

Pain responsive

Answer

Unresponsive

Question 4

During a nutritional assessment, which observation most warrants reporting to the nurse?

Accepted Answer

Patient has consumed less than 25% of meals for three days

Answer

Patient ate 75% of lunch

Answer

Patient prefers soup over solid foods

Answer

Patient drinks coffee with breakfast

Question 5

Which assessment technique is used to evaluate the equality and strength of pedal pulses?

Accepted Answer

Palpation of the dorsal foot arteries bilaterally

Answer

Auscultation of the lower legs

Answer

Percussion of the lower extremities

Answer

Inspection of nail beds only

Question 6

A patient who was alert and conversational this morning is now drowsy and only mumbles brief responses. This change most likely indicates:

Accepted Answer

A significant neurological or systemic change requiring immediate reporting

Answer

The patient is simply tired from activities

Answer

Normal afternoon fatigue in elderly patients

Answer

The patient needs a hearing evaluation

Question 7

When assessing a wound during dressing change, which finding requires immediate reporting?

Accepted Answer

Sudden increase in purulent, foul-smelling drainage

Answer

A small amount of clear serous drainage

Answer

Pink granulation tissue at the wound base

Answer

Wound edges that are well-approximated