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NURSING ASSISTANT APPLICATION

22 Concord St., 3rd Floor, Manchester, NH 03103 Fax: 603-647-2175
Office Phone: 603-647-2174


Last Name:
First Name:
MI:
Street Address: City:
 State:
 Zip Code:
Home Phone #:
Cell Phone #:
 Email Address:
Date of Birth:
Are you a US Citizen? Yes | No GED or Highest Grade Completed?
Social Security Number:
Emergency Contact Name: Phone #: Alternate Phone #:
Course Information:
Describe what you hope to achieve from this program:
Have you ever been convicted of a felony or misdemeanor?
No - OR - Yes

I would prefer to take:

Specific Start Date/Location -OR- Day Classes | Evening Classes | Weekend Classes | Anytime is fine

How did you hear about us?
Union Leader | Employment Times | The Telegraph | Fosters | The Citizen | Internet Search | TV | Friend/Family (name) or Other (please list specific source)
Certify:
I CERTIFY THAT ALL INFORMATION PROVIDED HEREIN IS TRUE AND COMPLETE AND THAT I HAVE TAKEN THIS TEST BY MYSELF WITHOUT ANY ASSISTANCE. I also certify that I have read the requirements, attendance, refund and criminal record policies. I agree to the terms and am able to fully meet the requirements. I further acknowledge that upon completion of the program if I wish to obtain a license, I must complete a NH State Police and FBI history check which includes fingerprint technology.   The information provided by the applicant on this application form will be held confidential. LNA Health Careers reserves the right to deny admission to any application, within the judgment of the Program Coordinator. Once accepted a photo ID is required to attach to your application for our file. [Per RSA188-D: 23 "Any (student) may cancel this transaction any time prior to midnight of the third business day after the date of this transaction".]
Please Check this box if you agree to these conditions. By checking this box you are electronically signing that you agree to the above terms and conditions:      
Date:           

Once you have completed this application, pre-test and submitted your application fee, please re-visit the application page (www.LNAHealthCareers.com/application.html) to print and sign a criminal history inquiry form. This form must be either mailed or faxed to the LNA Health Careers office to complete the application process.

At the conclusion of this form you will be taken to our Payment Page - your $35.00 (non-refundable) application/processing fee will be sent to:

LNA Health Careers, 22 Concord St., 3rd Floor, Manchester, NH 03101

*Please note, the application fee is for processing your application, it does not reserve your space in class.



This Space for Office Use Only  
Pre-Entrance Exam Score Accept Decline

Sponsor (If applicable)
Program Coordinator Signature Date



PRE-ENTRANCE EXAMINATION
22 Concord St., 3rd Floor, Manchester, NH 03101 Fax: 603-647-2175

Terminally ill patients need psychological and psychosocial support as well as physical care. Being a good listener is the best way to provide psychological support. Recognizing the five stages of dying will help you as a nurses assistant to be even more supportive of your patients, families and significant others. The patient may choose hospice care so they can remain at home rather than a hospital or long-term care setting.

 1. The writer discusses the importance of:
a.) A patient's life
b.) Providing support to a terminally ill patient
c.) The five stages of cancer
2. A dying patient needs psychological support. As an LNA you can provide that support by:
a.) Providing your own opinions about death
b.) Providing poor physical care
c.) Being a good listener
3. Some patients choose to die at home. This is an example of:
a.) Hospice care b.) Skilled nursing care c.) Long term care
4. Define the word “privacy”:

Calculations: Based on the information that  30cc = 1 ounce, calculate the following:
5.) 15cc = ounce
6.) 120cc = ounces
7.) 2 ounces = cc's
8.) 6 ounces = cc's
9. A Nursing Assistant can show that he/she is listening carefuly to a patient by:
a.) Looking away while the patient talks
b.) Responding to the patient when appropriate
c.) Rolling their eyes when the patient says something they don't agree with
d.) Changing the subject
10. Most patients would prefer:
a.) To skip meals
b.) To feed themselves
c.) To eat when nauseated
d.) To be fed

11. A patient is on isolation. This means they are:
a) Depressed
b) Separated
c) Blended
d) Connected
12. If a patient has a terminal disease, it is:
a.) Fast
b.) Curable
c.) Incurable
d.) Non-threatening
13. Skin damage caused by __________ is a burn: 
a.) Soap
b.) Rain
c.) Germs
d.) Heat

14. Which word means the opposite of safe?   a.) Protected   b.) Harmful c.) Secure d.) Careful
15. What type of non-verbal communication describes a patient who is sad and depressed?
a.) A patient that participates in activities
b.) A patient that stays in their room and cries
c.) A patient that volunteers to help other peers
d.) A patient that smiles at all the visitors that pass by

Before you submit this to us, please remember that this is an application and a pre-entrance examination. Every answer is important.

Take a few moments to go back over the application and pre-test. There aren't any automatic checks to see if you've filled in all the blanks. If they are empty they will be marked incorrect and this will affect your pre-test score.