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: The correct answer is B: Broken skin between the toenails. This should be reported as a possible sign of a pressure injury because it indicates skin breakdown, which can be a precursor to pressure ulcers. Broken skin between the toenails is a specific area where pressure injuries can develop due to friction and pressure. It is important to report this promptly to prevent further damage and provide appropriate care. A: Intact skin is not a sign of a pressure injury, so it does not need to be reported. C: Clean skin is a positive sign of good hygiene and does not necessarily indicate a pressure injury. D: Adequate resident hydration is important for overall health but does not directly relate to pressure injuries.

Correct Answer: C

Rationale: The correct answer is C because dementia indeed affects the ability to reason and remember due to brain damage. It is not always reversible (A), as it is often progressive and irreversible. It is not a sudden state of confusion (B), but a gradual decline in cognitive function. Lastly, dementia is a serious illness (D) that can significantly impact a person's quality of life and independence.

Correct Answer: C

Rationale: The correct answer is C: Breakthrough pain. Breakthrough pain is a sudden and intense flare-up of pain that occurs despite the patient being on a regular pain management regimen. This type of pain is common in cancer patients due to various factors such as tumor progression or treatment-related side effects. Expressive pain (A) and Receptive pain (D) are not recognized medical terms related to cancer pain. Obstructive pain (B) refers to pain caused by physical blockages in the body, not typically associated with cancer-related pain. In summary, Breakthrough pain is the most appropriate term to describe the sudden and severe pain episodes experienced by some cancer patients despite their ongoing pain management efforts.

Correct Answer: C

Rationale: The correct answer is C because allowing private visits from family and friends promotes social connections and emotional support, crucial for a successful restorative care program. It helps residents maintain relationships, independence, and overall well-being. Choice A is incorrect as it may disrupt rest and recovery. Choice B is incorrect because relationships are important for emotional support. Choice D is incorrect as residents should be empowered to make their own decisions.

Correct Answer: B

Rationale: The correct answer is B because promptly reporting a request for a clergy visit can provide spiritual support and guidance to the family during a difficult time. This option respects the family's beliefs and preferences, offering them a source of comfort and solace. By involving a clergy member, the family can receive emotional support and guidance in coping with the loss. Choices A, C, and D are incorrect: A: Influencing the family with the NA's religion is inappropriate as it may not align with the family's beliefs, potentially causing discomfort. C: Isolating the family and friends is detrimental as social support is crucial in the grieving process. D: Judging past behavior to make the family feel better is judgmental and may lead to added emotional distress.