NUR 216 – HEALTH ASSESSMENT EXAM 2 WITH CORRECTLY
ANSWERED QUESTIONS GRADED A+ 2025.
Question 1
A primary theme in nursing assessment, highlighted in the sources, is the critical importance of
performing a thorough skin assessment:
A) Only for patients with existing skin conditions.
B) Upon patient admission to identify immediate risks and establish a baseline.
C) Annually for all patients as part of a routine check-up.
D) Exclusively during wound care.
E) Only if the patient complains of skin problems.
Correct Answer: B) Upon patient admission to identify immediate risks and establish a
baseline
Rationale: A comprehensive skin assessment upon admission is crucial for identifying any
immediate risks (e.g., pressure injury susceptibility) and establishing a baseline for future
comparisons, allowing for early detection of changes.
Question 2
When assessing a patient's skin complaints to gather comprehensive subjective data, the nurse
should utilize which framework?
A) PERRLA Method.
B) ABCDE Method.
C) OPQRST Method.
D) Braden Scale.
E) Glasgow Coma Scale.
Correct Answer: C) OPQRST Method
Rationale: The OPQRST method (Onset, Provocation/Palliative, Quality, Region/Radiation,
Severity, Timing) is a standardized framework for gathering comprehensive subjective
data about symptoms, including pain or skin complaints, helping to elicit detailed
information from the patient.
Question 3
Which assessment finding demands immediate follow-up, taking precedence over other
abnormal but less critical vital signs?
A) A blood pressure of 130/85 mmHg.
B) A heart rate of 110 beats/minute.
C) Angioedema (swelling of the face, lips, or tongue).
D) A respiratory rate of 22 breaths/minute.
E) A temperature of 99.8°F (37.7°C).
Correct Answer: C) Angioedema
Rationale: Angioedema, particularly affecting the face, lips, or tongue, is a sign of a severe
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allergic reaction (anaphylaxis) that can rapidly compromise the airway. Airway
compromise is a first-level priority and demands immediate intervention, taking
precedence over other vital signs that, while abnormal, are less acutely life-threatening.
Question 4
A post-surgical patient has an oxygen saturation of 89%, a blood pressure of 140/90, rates their
pain as 2/10, and reports a new feeling of tightness in their chest. Which finding requires the
most immediate follow-up?
A) Oxygen saturation of 89%.
B) Blood pressure of 140/90 mmHg.
C) Pain rated as 2/10.
D) New feeling of tightness in their chest.
E) All findings require equal immediate follow-up.
Correct Answer: D) New feeling of tightness in their chest
Rationale: A new feeling of tightness in the chest, especially in a post-surgical patient, is a
critical symptom that can indicate life-threatening conditions such as pulmonary embolism,
myocardial infarction, or pneumothorax. While an oxygen saturation of 89% is also a
critical finding, the new symptom of chest tightness often points to an acute underlying
process that needs urgent investigation, potentially explaining the low SpO2. This symptom
requires immediate evaluation and intervention.
Question 5
The primary focus of clinical prioritization should always be on which type of patient problem?
A) A chronic, stable problem.
B) A problem that can be easily delegated.
C) An active, acute problem that poses an immediate threat to the patient's well-being.
D) A problem that aligns with the nurse's personal interests.
E) A problem that has been present for a long time.
Correct Answer: C) An active, acute problem
Rationale: Clinical prioritization in nursing always places an active, acute problem that
poses an immediate threat to the patient's safety or physiological stability (e.g., airway,
breathing, circulation issues) at the highest priority. Chronic or stable problems are
addressed after acute, life-threatening issues are managed.
Question 6
The standardized tool specifically used for documenting a patient's risk for developing pressure
injuries is the:
A) Glasgow Coma Scale.
B) Braden scale.
C) APGAR score.
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D) Morse Fall Scale.
E) Norton scale.
Correct Answer: B) Braden scale
Rationale: The Braden Scale is a widely used, evidence-based tool that assesses a patient's
risk for pressure injury development based on six subscales: sensory perception, moisture,
activity, mobility, nutrition, and friction/shear. A lower score indicates a higher risk.
Question 7
Key factors in assessing a patient's risk for skin breakdown include the presence of:
A) Clear and dry skin.
B) Normal skin turgor.
C) Moisture and existing lesions.
D) Intact skin elasticity.
E) Good nutritional status.
Correct Answer: C) Moisture and existing lesions
Rationale: Excessive moisture (e.g., from incontinence, wound drainage) macerates the skin,
making it more fragile and susceptible to breakdown. Existing lesions (e.g., abrasions,
rashes) also compromise skin integrity. These factors significantly increase the risk for
pressure injuries and other forms of skin breakdown.
Question 8
For patients with dark skin, the most reliable location to assess for cyanosis is the:
A) Extremities.
B) Nail beds.
C) Mucous membranes.
D) Face.
E) Chest.
Correct Answer: C) Mucous membranes
Rationale: In individuals with dark skin tones, cyanosis (bluish discoloration due to
hypoxemia) can be difficult to detect on the skin. The most reliable locations to assess for
cyanosis are the mucous membranes (e.g., oral mucosa, conjunctiva) and the nail beds,
where the lack of melanin allows for better visualization of color changes.
Question 9
Changes in moles that indicate concern for melanoma should be evaluated using which
standardized assessment methodology?
A) OPQRST Method.
B) PERRLA Method.
C) ABCDE Method.
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D) Braden Scale.
E) Romberg Test.
Correct Answer: C) ABCDE Method
Rationale: The ABCDE method is a standardized mnemonic used to assess moles for
characteristics that may indicate melanoma: Asymmetry, Border irregularity, Color
variation, Diameter greater than 6mm, and Evolving (changes in size, shape, color,
elevation, or new symptoms like itching or bleeding).
Question 10
Which finding can be a suspicious finding for melanoma, according to the source material?
A) A papule.
B) A macule.
C) A uniformly brown, flat nevus.
D) A lesion with symmetrical borders.
E) A small, round, unchanging lesion.
Correct Answer: A) A papule.
Rationale: While melanoma can present in various ways, a papule (a solid, elevated lesion)
that exhibits suspicious ABCDE characteristics (e.g., irregular borders, color variation,
increasing diameter, or evolution) can be a concerning finding for melanoma. Melanoma is
not exclusively macular. The provided answer states "A papule" could be suspicious.
Question 11
The expected finding for a Stage II pressure injury is an eroded layer of skin accompanied by:
A) Exposed bone or muscle.
B) Full-thickness skin loss.
C) Exudate (serum or pus) or a ruptured serum-filled blister.
D) Intact skin with non-blanchable redness.
E) Deep tissue injury.
Correct Answer: C) Exudate
Rationale: A Stage II pressure injury involves partial-thickness skin loss of the dermis,
presenting as a shallow open ulcer with a red-pink wound bed without slough. It may also
present as an intact or ruptured serum-filled blister, and often involves the presence of
exudate.
Question 12
A positive sign that a pressure injury is healing includes confirmation that:
A) Muscle or bone are no longer exposed.
B) The wound bed is increasing in size.
C) Increased slough and eschar are present.
ANSWERED QUESTIONS GRADED A+ 2025.
Question 1
A primary theme in nursing assessment, highlighted in the sources, is the critical importance of
performing a thorough skin assessment:
A) Only for patients with existing skin conditions.
B) Upon patient admission to identify immediate risks and establish a baseline.
C) Annually for all patients as part of a routine check-up.
D) Exclusively during wound care.
E) Only if the patient complains of skin problems.
Correct Answer: B) Upon patient admission to identify immediate risks and establish a
baseline
Rationale: A comprehensive skin assessment upon admission is crucial for identifying any
immediate risks (e.g., pressure injury susceptibility) and establishing a baseline for future
comparisons, allowing for early detection of changes.
Question 2
When assessing a patient's skin complaints to gather comprehensive subjective data, the nurse
should utilize which framework?
A) PERRLA Method.
B) ABCDE Method.
C) OPQRST Method.
D) Braden Scale.
E) Glasgow Coma Scale.
Correct Answer: C) OPQRST Method
Rationale: The OPQRST method (Onset, Provocation/Palliative, Quality, Region/Radiation,
Severity, Timing) is a standardized framework for gathering comprehensive subjective
data about symptoms, including pain or skin complaints, helping to elicit detailed
information from the patient.
Question 3
Which assessment finding demands immediate follow-up, taking precedence over other
abnormal but less critical vital signs?
A) A blood pressure of 130/85 mmHg.
B) A heart rate of 110 beats/minute.
C) Angioedema (swelling of the face, lips, or tongue).
D) A respiratory rate of 22 breaths/minute.
E) A temperature of 99.8°F (37.7°C).
Correct Answer: C) Angioedema
Rationale: Angioedema, particularly affecting the face, lips, or tongue, is a sign of a severe
,[Type here]
allergic reaction (anaphylaxis) that can rapidly compromise the airway. Airway
compromise is a first-level priority and demands immediate intervention, taking
precedence over other vital signs that, while abnormal, are less acutely life-threatening.
Question 4
A post-surgical patient has an oxygen saturation of 89%, a blood pressure of 140/90, rates their
pain as 2/10, and reports a new feeling of tightness in their chest. Which finding requires the
most immediate follow-up?
A) Oxygen saturation of 89%.
B) Blood pressure of 140/90 mmHg.
C) Pain rated as 2/10.
D) New feeling of tightness in their chest.
E) All findings require equal immediate follow-up.
Correct Answer: D) New feeling of tightness in their chest
Rationale: A new feeling of tightness in the chest, especially in a post-surgical patient, is a
critical symptom that can indicate life-threatening conditions such as pulmonary embolism,
myocardial infarction, or pneumothorax. While an oxygen saturation of 89% is also a
critical finding, the new symptom of chest tightness often points to an acute underlying
process that needs urgent investigation, potentially explaining the low SpO2. This symptom
requires immediate evaluation and intervention.
Question 5
The primary focus of clinical prioritization should always be on which type of patient problem?
A) A chronic, stable problem.
B) A problem that can be easily delegated.
C) An active, acute problem that poses an immediate threat to the patient's well-being.
D) A problem that aligns with the nurse's personal interests.
E) A problem that has been present for a long time.
Correct Answer: C) An active, acute problem
Rationale: Clinical prioritization in nursing always places an active, acute problem that
poses an immediate threat to the patient's safety or physiological stability (e.g., airway,
breathing, circulation issues) at the highest priority. Chronic or stable problems are
addressed after acute, life-threatening issues are managed.
Question 6
The standardized tool specifically used for documenting a patient's risk for developing pressure
injuries is the:
A) Glasgow Coma Scale.
B) Braden scale.
C) APGAR score.
,[Type here]
D) Morse Fall Scale.
E) Norton scale.
Correct Answer: B) Braden scale
Rationale: The Braden Scale is a widely used, evidence-based tool that assesses a patient's
risk for pressure injury development based on six subscales: sensory perception, moisture,
activity, mobility, nutrition, and friction/shear. A lower score indicates a higher risk.
Question 7
Key factors in assessing a patient's risk for skin breakdown include the presence of:
A) Clear and dry skin.
B) Normal skin turgor.
C) Moisture and existing lesions.
D) Intact skin elasticity.
E) Good nutritional status.
Correct Answer: C) Moisture and existing lesions
Rationale: Excessive moisture (e.g., from incontinence, wound drainage) macerates the skin,
making it more fragile and susceptible to breakdown. Existing lesions (e.g., abrasions,
rashes) also compromise skin integrity. These factors significantly increase the risk for
pressure injuries and other forms of skin breakdown.
Question 8
For patients with dark skin, the most reliable location to assess for cyanosis is the:
A) Extremities.
B) Nail beds.
C) Mucous membranes.
D) Face.
E) Chest.
Correct Answer: C) Mucous membranes
Rationale: In individuals with dark skin tones, cyanosis (bluish discoloration due to
hypoxemia) can be difficult to detect on the skin. The most reliable locations to assess for
cyanosis are the mucous membranes (e.g., oral mucosa, conjunctiva) and the nail beds,
where the lack of melanin allows for better visualization of color changes.
Question 9
Changes in moles that indicate concern for melanoma should be evaluated using which
standardized assessment methodology?
A) OPQRST Method.
B) PERRLA Method.
C) ABCDE Method.
, [Type here]
D) Braden Scale.
E) Romberg Test.
Correct Answer: C) ABCDE Method
Rationale: The ABCDE method is a standardized mnemonic used to assess moles for
characteristics that may indicate melanoma: Asymmetry, Border irregularity, Color
variation, Diameter greater than 6mm, and Evolving (changes in size, shape, color,
elevation, or new symptoms like itching or bleeding).
Question 10
Which finding can be a suspicious finding for melanoma, according to the source material?
A) A papule.
B) A macule.
C) A uniformly brown, flat nevus.
D) A lesion with symmetrical borders.
E) A small, round, unchanging lesion.
Correct Answer: A) A papule.
Rationale: While melanoma can present in various ways, a papule (a solid, elevated lesion)
that exhibits suspicious ABCDE characteristics (e.g., irregular borders, color variation,
increasing diameter, or evolution) can be a concerning finding for melanoma. Melanoma is
not exclusively macular. The provided answer states "A papule" could be suspicious.
Question 11
The expected finding for a Stage II pressure injury is an eroded layer of skin accompanied by:
A) Exposed bone or muscle.
B) Full-thickness skin loss.
C) Exudate (serum or pus) or a ruptured serum-filled blister.
D) Intact skin with non-blanchable redness.
E) Deep tissue injury.
Correct Answer: C) Exudate
Rationale: A Stage II pressure injury involves partial-thickness skin loss of the dermis,
presenting as a shallow open ulcer with a red-pink wound bed without slough. It may also
present as an intact or ruptured serum-filled blister, and often involves the presence of
exudate.
Question 12
A positive sign that a pressure injury is healing includes confirmation that:
A) Muscle or bone are no longer exposed.
B) The wound bed is increasing in size.
C) Increased slough and eschar are present.
