Trivium Patient Assessment and Evaluation 5

Question 1

When taking an apical pulse, the nurse aide places the stethoscope at which anatomical landmark?

Accepted Answer

Left midclavicular line, 5th intercostal space

Answer

Right midclavicular line, 2nd intercostal space

Answer

Center of the sternum

Answer

Right lateral chest wall

Question 2

A patient is assessed using the PAINAD scale. This scale is specifically designed for:

Accepted Answer

Patients with advanced dementia who cannot self-report pain

Answer

Patients who are post-surgical

Answer

Patients experiencing chronic low back pain

Answer

Pediatric patients under age 5

Question 3

Which assessment finding would be considered a normal variant in an elderly patient?

Accepted Answer

Decreased skin turgor due to natural loss of elasticity

Answer

New onset of confusion

Answer

Sudden weight loss of 10 lbs in one week

Answer

Resting heart rate of 120 beats per minute

Question 4

During a patient intake assessment, the nurse aide should report which of the following findings related to medication?

Accepted Answer

The patient takes warfarin (a blood thinner) daily

Answer

The patient takes a daily multivitamin

Answer

The patient takes aspirin occasionally for headaches

Answer

The patient drinks chamomile tea at bedtime

Question 5

A patient's Glasgow Coma Scale (GCS) score is 15. What does this indicate?

Accepted Answer

The patient is fully conscious with normal neurological function

Answer

The patient is unresponsive

Answer

The patient has a severe brain injury

Answer

The patient has moderate cognitive impairment

Question 6

When documenting a patient's pain assessment, which entry meets documentation standards?

Accepted Answer

Patient c/o chest pain 6/10, sharp, onset 30 min ago, not relieved by position change. RN notified.

Answer

Patient seems to be in pain

Answer

Patient uncomfortable, will monitor

Answer

Checked on patient, no complaints noted

Question 7

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:

Accepted Answer

Possible hip fracture requiring immediate medical evaluation

Answer

Evaluating the patient's pain tolerance level

Answer

Determining if the patient fell due to non-compliance

Answer

Assessing the floor surface for safety hazards