Health Assessment EXAM2

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Sample questions from Health Assessment EXAM2

This material has 90 questions with answers and rationales. Here are the first 5.

1. 1.During a community clinic visit, a client points out a new pigmented lesion on the upper back. Which documentation best supports comparison at a later assessment?

   • A.A dark lesion is present on the back and should be monitored.
   • B.A raised brown lesion is present on the upper back; photograph obtained.
   • C.A suspicious mole is present on the back; the client reports that it has changed.
   • D.A 7-mm asymmetric, variegated brown-and-black lesion with an irregular border is present on the upper right back, 4 cm below the scapula.

   Rationale: The most complete description records the lesion's size, shape, color, border, and precise location, making it possible to compare changes over time. The other descriptions omit key characteristics or a precise location, even though the client's report of change and a photograph may be useful additional information. Documenting only that a lesion is suspicious does not replace objective description.

2. 2.At a long-term care facility, an immobile client has intact skin but is at risk for pressure injury. Which actions support skin protection? Select all that apply.

   • A.Massage a reddened area over the sacrum to increase local circulation.
   • B.Use a repositioning plan that reduces prolonged pressure on the same area.
   • C.Use a ring-shaped cushion to completely offload the sacrum.
   • D.Inspect pressure points routinely and document any change in skin condition.
   • E.Keep skin clean and dry and address moisture from perspiration or incontinence.

   Rationale: Routine inspection helps identify early skin changes, while repositioning and moisture control reduce contributors to skin breakdown. Massaging persistent redness can damage vulnerable tissue, and ring-shaped cushions can concentrate pressure around the area rather than reliably offloading it. Skin protection relies on reducing pressure and friction while keeping skin clean and appropriately dry.

3. 3.An older adult says, "My mouth has been dry, and I have barely urinated today." The skin over the hand remains tented briefly after being pinched. Which interpretation is most appropriate?

   • A.Skin turgor can be less reliable with aging; assess additional indicators such as oral mucosa, intake, and urine output.
   • B.Skin turgor is expected to be delayed in all older adults and should not be documented.
   • C.The finding indicates fluid excess because older adults normally have decreased skin elasticity.
   • D.The tenting confirms dehydration, so no other assessment is needed.

   Rationale: Age-related loss of skin elasticity can make turgor less reliable as a standalone indicator of fluid status, so it should be interpreted with other findings. Dry oral mucosa and reduced urine output add relevant cues that warrant further fluid-balance assessment. Tenting neither confirms dehydration by itself nor indicates fluid excess, and an abnormal finding should still be documented.

4. 4.A newborn has small white papules across the nose and cheeks but is feeding well and has no fever or surrounding redness. Which response is most appropriate?

   • A.Recommend applying an over-the-counter acne medication twice daily.
   • B.Explain that these may be milia, a common newborn finding, and advise the caregiver not to squeeze them.
   • C.Scrub the papules gently to clear the pores.
   • D.Describe the papules as a sign of bacterial infection and arrange immediate treatment.

   Answer and rationale are in the full material.

5. 5.At an outpatient visit, a client who smokes has thickened, curved fingernails and reports increasing shortness of breath. Which assessment finding is most important to communicate for further evaluation?

   • A.A small white spot on one nail after a recent manicure
   • B.Longitudinal ridges on several fingernails
   • C.Loss of the normal angle between the nail plate and proximal nail fold with bulbous fingertips
   • D.Nail beds that blanch and return to pink within 2 seconds

   Answer and rationale are in the full material.