Health Assessment Exam 2
Questions And Verified Answers|
2026/27 Updated
EXAM
Skin, Hair, and Nails (1–12)
1. A patient has a circular, non-blanching, dark red lesion on
the sacrum that is intact. The nurse stages this pressure injury
as:
Answer: Stage I
Rationale: Stage I pressure injury presents as intact skin with
non-blanchable redness, usually over a bony prominence.
2. Which finding is most suggestive of a malignant
melanoma?
Answer: A pigmented lesion with irregular borders and
multiple colors.
Rationale: Asymmetry, border irregularity, color variation,
diameter >6 mm, and evolution (ABCDE) are melanoma
warning signs.
3. A 70-year-old patient has several small, flat, brown macules
on the sun-exposed areas of the hands and forearms. These
are most likely:
Answer: Solar lentigines (liver spots)
, Rationale: Solar lentigines are common benign aging
changes from cumulative sun exposure; they do not require
treatment.
4. When assessing turgor in an older adult, the skin on the
sternum remains tented for a few seconds. This indicates:
Answer: Decreased skin elasticity (common with aging) or
possible dehydration.
Rationale: Skin turgor may normally be decreased in aging
due to loss of elastic fibers; correlate with other signs of
hydration.
5. The nurse notes yellowish, waxy, thick plaques on the
upper and lower eyelids of a middle-aged patient. This
finding is:
Answer: Xanthelasma
Rationale: Xanthelasma are cholesterol deposits often
associated with hyperlipidemia; refer for lipid profile.
6. A patient has a deep, open wound over the heel with visible
adipose tissue but no muscle or bone exposure. What stage?
Answer: Stage III pressure injury
Rationale: Stage III involves full-thickness skin loss with
visible subcutaneous fat; bone/tendon/muscle not exposed.
7. During inspection of the nails, the nurse notes a
160-degree angle between the nail base and the proximal nail
fold. This is:
Answer: Normal finding
, Rationale: The normal Lovibond angle is about 160 degrees.
Clubbing would show >180 degrees.
8. A patient complains of hair thinning. The nurse observes
diffuse, symmetric hair loss on the scalp without scarring. This
is most consistent with:
Answer: Androgenetic alopecia (male/female pattern
baldness)
Rationale: Diffuse, nonscarring hair loss is typical of
hereditary balding; other causes include telogen effluvium.
9. Which of the following skin lesions is precancerous and
commonly found on sun-exposed skin?
Answer: Actinic keratosis
Rationale: Actinic keratosis is a rough, scaly patch that can
progress to squamous cell carcinoma.
10. A dark-skinned patient has a bluish tint to the lips and nail
beds. The nurse should first:
Answer: Assess oxygen saturation and check for hypoxia.
Rationale: Cyanosis in dark skin may appear as grayish or
bluish hue in mucous membranes and nail beds; always
confirm with pulse oximetry.
11. The nurse notes a “strawberry” appearance of the tongue.
This is most characteristic of:
Answer: Nutritional deficiency (e.g., niacin, B12, folate) or
Kawasaki disease.
, Rationale: Strawberry tongue (red, swollen with prominent
papillae) is seen in certain vitamin deficiencies and Kawasaki.
12. A patient with diabetes has a painless, deep ulcer on the
plantar surface of the foot with surrounding callus. This is
most likely a:
Answer: Neuropathic ulcer (diabetic foot ulcer)
Rationale: Neuropathy leads to unnoticed trauma and callus
formation; pressure points cause ulceration.
Head, Eyes, Ears, Nose, Throat (13–32)
13. The nurse assesses pupillary accommodation. What is the
expected response?
Answer: Pupils constrict when the gaze shifts from far to
near.
Rationale: Accommodation involves pupillary constriction,
convergence, and lens thickening for near vision.
14. A patient has a positive Romberg test. This indicates:
Answer: Impaired proprioception or vestibular function.
Rationale: Romberg sign (swaying with eyes closed)
suggests sensory ataxia or vestibular dysfunction.
15. The whisper test is used to assess:
Answer: Hearing acuity.
Questions And Verified Answers|
2026/27 Updated
EXAM
Skin, Hair, and Nails (1–12)
1. A patient has a circular, non-blanching, dark red lesion on
the sacrum that is intact. The nurse stages this pressure injury
as:
Answer: Stage I
Rationale: Stage I pressure injury presents as intact skin with
non-blanchable redness, usually over a bony prominence.
2. Which finding is most suggestive of a malignant
melanoma?
Answer: A pigmented lesion with irregular borders and
multiple colors.
Rationale: Asymmetry, border irregularity, color variation,
diameter >6 mm, and evolution (ABCDE) are melanoma
warning signs.
3. A 70-year-old patient has several small, flat, brown macules
on the sun-exposed areas of the hands and forearms. These
are most likely:
Answer: Solar lentigines (liver spots)
, Rationale: Solar lentigines are common benign aging
changes from cumulative sun exposure; they do not require
treatment.
4. When assessing turgor in an older adult, the skin on the
sternum remains tented for a few seconds. This indicates:
Answer: Decreased skin elasticity (common with aging) or
possible dehydration.
Rationale: Skin turgor may normally be decreased in aging
due to loss of elastic fibers; correlate with other signs of
hydration.
5. The nurse notes yellowish, waxy, thick plaques on the
upper and lower eyelids of a middle-aged patient. This
finding is:
Answer: Xanthelasma
Rationale: Xanthelasma are cholesterol deposits often
associated with hyperlipidemia; refer for lipid profile.
6. A patient has a deep, open wound over the heel with visible
adipose tissue but no muscle or bone exposure. What stage?
Answer: Stage III pressure injury
Rationale: Stage III involves full-thickness skin loss with
visible subcutaneous fat; bone/tendon/muscle not exposed.
7. During inspection of the nails, the nurse notes a
160-degree angle between the nail base and the proximal nail
fold. This is:
Answer: Normal finding
, Rationale: The normal Lovibond angle is about 160 degrees.
Clubbing would show >180 degrees.
8. A patient complains of hair thinning. The nurse observes
diffuse, symmetric hair loss on the scalp without scarring. This
is most consistent with:
Answer: Androgenetic alopecia (male/female pattern
baldness)
Rationale: Diffuse, nonscarring hair loss is typical of
hereditary balding; other causes include telogen effluvium.
9. Which of the following skin lesions is precancerous and
commonly found on sun-exposed skin?
Answer: Actinic keratosis
Rationale: Actinic keratosis is a rough, scaly patch that can
progress to squamous cell carcinoma.
10. A dark-skinned patient has a bluish tint to the lips and nail
beds. The nurse should first:
Answer: Assess oxygen saturation and check for hypoxia.
Rationale: Cyanosis in dark skin may appear as grayish or
bluish hue in mucous membranes and nail beds; always
confirm with pulse oximetry.
11. The nurse notes a “strawberry” appearance of the tongue.
This is most characteristic of:
Answer: Nutritional deficiency (e.g., niacin, B12, folate) or
Kawasaki disease.
, Rationale: Strawberry tongue (red, swollen with prominent
papillae) is seen in certain vitamin deficiencies and Kawasaki.
12. A patient with diabetes has a painless, deep ulcer on the
plantar surface of the foot with surrounding callus. This is
most likely a:
Answer: Neuropathic ulcer (diabetic foot ulcer)
Rationale: Neuropathy leads to unnoticed trauma and callus
formation; pressure points cause ulceration.
Head, Eyes, Ears, Nose, Throat (13–32)
13. The nurse assesses pupillary accommodation. What is the
expected response?
Answer: Pupils constrict when the gaze shifts from far to
near.
Rationale: Accommodation involves pupillary constriction,
convergence, and lens thickening for near vision.
14. A patient has a positive Romberg test. This indicates:
Answer: Impaired proprioception or vestibular function.
Rationale: Romberg sign (swaying with eyes closed)
suggests sensory ataxia or vestibular dysfunction.
15. The whisper test is used to assess:
Answer: Hearing acuity.
