Which of the following should be reported by the nursing assistant because it is a possible sign of a pressure injury?

Correct Answer: B

Rationale: Correct Answer: B - Broken skin between the toenails Rationale: Broken skin between the toenails can indicate the presence of a pressure injury, also known as a pressure ulcer. Pressure injuries often start as damage to the skin, such as breaks or tears, and can progress to more severe stages if not addressed promptly. Summary of Other Choices: A: Intact skin - This is not a sign of a pressure injury as intact skin does not show any visible damage or breakdown. C: Clean skin - Clean skin does not necessarily indicate the presence of a pressure injury, as cleanliness alone does not provide information on skin integrity. D: Adequate resident hydration - While hydration is important for overall skin health, it is not a direct indicator of a pressure injury.

Correct Answer: C

Rationale: The correct answer is C: It affects the ability to reason and remember. Dementia is a progressive condition that impairs cognitive functions such as reasoning, memory, and decision-making. This statement is true as dementia specifically targets these cognitive abilities. A: It is always reversible - This statement is incorrect as dementia is typically irreversible and degenerative in nature. B: It is a sudden state of confusion - This statement is incorrect as dementia develops gradually over time and is not a sudden onset condition. D: It is not a serious illness - This statement is incorrect as dementia is a serious and debilitating condition that requires proper management and care.

Correct Answer: C

Rationale: The correct answer is C: Breakthrough pain. Breakthrough pain is a type of severe pain that occurs unexpectedly in cancer patients, even when they are already on pain medications. It "breaks through" the regular pain control regimen. This type of pain is often intense and short-lived, requiring immediate treatment. Expressive pain (A) and Receptive pain (D) are not recognized medical terms. Obstructive pain (B) refers to pain caused by physical blockages and is not typically associated with cancer-related pain.

Correct Answer: C

Rationale: The correct answer is C: Allow for private visits from family and friends. This choice promotes emotional support and social interaction, which are essential for a successful restorative care program. It helps residents maintain connections and improves their overall well-being. A: Creating a loud vibrant environment may disrupt rest and recovery. B: Discouraging relationships between residents goes against the goal of fostering social connections. D: Making most daily decisions for residents limits their autonomy and independence, which are key aspects of restorative care.

Correct Answer: B

Rationale: The correct answer is B: Promptly reporting a request for a clergy visit. This is the best choice because it shows empathy and support for the family's spiritual and emotional needs during a difficult time. It respects the family's beliefs and values, providing them with the necessary support from a clergy member. It helps the family cope with their grief and find comfort in their faith. Choice A is incorrect as imposing personal religious beliefs on the family may not align with their own beliefs, causing discomfort. Choice C is incorrect as isolating the family and friends can lead to further emotional distress and hinder the grieving process. Choice D is incorrect as judging past behavior is not helpful and may cause additional emotional pain for the family.