Relias Assessment and Evaluation 2 — Questions and Answers
Question 1: A nurse is conducting a fall risk assessment using the Morse Fall Scale. Which factor carries the HIGHEST point value on this tool?
- History of falling within the past 3 months (Correct answer)
- Secondary diagnosis present
- Use of intravenous therapy or heparin lock
- Impaired gait or transfer ability
Correct answer: History of falling within the past 3 months
History of falling within the past 3 months carries 25 points, the highest single-item score on the Morse Fall Scale.
Question 2: When using the Glasgow Coma Scale (GCS), which component assesses verbal response?
- Eye opening to verbal stimuli
- Ability to state name, date, and location
- Oriented, confused, inappropriate, incomprehensible, or none (Correct answer)
- Motor response to commands
Correct answer: Oriented, confused, inappropriate, incomprehensible, or none
The verbal response component of the GCS is scored from 5 (oriented) to 1 (none), evaluating responses such as oriented, confused, inappropriate words, incomprehensible sounds, or no response.
Question 3: A clinician documents a patient's pain as 7/10 using a numeric rating scale. This represents which level of measurement?
- Nominal
- Ordinal (Correct answer)
- Interval
- Ratio
Correct answer: Ordinal
Numeric pain rating scales are ordinal because the numbers indicate rank order but do not have equal intervals between values.
Question 4: Which assessment tool is BEST suited for detecting delirium in hospitalized older adults?
- Montreal Cognitive Assessment (MoCA)
- Confusion Assessment Method (CAM) (Correct answer)
- Mini-Mental State Examination (MMSE)
- Beck Depression Inventory (BDI)
Correct answer: Confusion Assessment Method (CAM)
The Confusion Assessment Method (CAM) is a validated, widely used tool specifically designed to identify delirium at the bedside.
Question 5: An evaluator notes that two raters score the same client differently on a behavioral checklist. This represents a problem with:
- Content validity
- Inter-rater reliability (Correct answer)
- Test-retest reliability
- Construct validity
Correct answer: Inter-rater reliability
Inter-rater reliability refers to the degree of agreement between two or more independent raters evaluating the same subject.
Question 6: During a comprehensive skin assessment, a stage 2 pressure injury is BEST described as:
- Non-blanchable erythema of intact skin
- Partial-thickness loss involving the dermis (Correct answer)
- Full-thickness tissue loss with exposed bone
- Full-thickness loss with slough or eschar
Correct answer: Partial-thickness loss involving the dermis
Stage 2 pressure injuries involve partial-thickness loss of the dermis and present as a shallow open ulcer or intact/ruptured blister.
Question 7: Which principle of assessment states that a test should measure what it is intended to measure?
- Reliability
- Sensitivity
- Validity (Correct answer)
- Specificity
Correct answer: Validity
Validity is the degree to which an assessment tool accurately measures the construct or outcome it is designed to assess.
Relias Assessment and Evaluation 2
A nurse is conducting a fall risk assessment using the Morse Fall Scale.
Which factor carries the HIGHEST point value on this tool?