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

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?

Accepted Answer

BP 88/52, HR 118, Temp 103.2°F

Answer

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?

Accepted Answer

Voice responsive

Answer

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?

Accepted Answer

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

Answer

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?

Accepted Answer

Palpation of the dorsal foot arteries bilaterally

Answer

Pedal pulses are assessed by palpating the dorsalis pedis and posterior tibial arteries and comparing both sides.

(Trivium) Trivium Health Care Exam Practice Test

(Trivium) Trivium Health Care Exam Practice Test

Trivium Patient Assessment and Evaluation 3