NUR 2092/NUR2092 Exam 4 V1 | Health
Assessment Q&A with Rationale |
Rasmussen University
1. When assessing a patient’s skin turgor, where is the most reliable location to pinch the skin
on an elderly adult?
A. The back of the hand
B. Under the clavicle
C. The forearm
D. The abdomen
Correct Answer: B
Expert Explanation: In elderly patients, skin on the hands and arms loses elasticity,
making it an unreliable site for testing hydration. The skin under the clavicle or over the
sternum provides a more accurate assessment of turgor and hydration status. Tenting in
these areas indicates a significant loss of fluid or dehydration.
2. A nurse is performing a pupillary light reflex test. Which cranial nerve is primarily
responsible for the constrictive response to light?
A. Cranial Nerve III
B. Cranial Nerve II
C. Cranial Nerve IV
,D. Cranial Nerve VI
Correct Answer: A
Expert Explanation: Cranial Nerve III, also known as the Oculomotor nerve, is responsible
for pupil constriction and eyelid movement. While Cranial Nerve II (Optic) senses the light,
the motor response of constriction is carried out by CN III. Damage to this nerve can result
in a fixed or dilated pupil that does not react to light stimuli.
3. During an otoscopic examination of an adult, the nurse should pull the pinna in which
direction to straighten the ear canal?
A. Down and back
B. Up and back
C. Straight back
D. Up and forward
Correct Answer: B
Expert Explanation: For adult patients, the pinna is pulled up and back to align the ear
canal for better visualization of the tympanic membrane. In contrast, for children under the
age of three, the pinna is pulled down and back due to the different anatomical orientation
of their ear canals. This technique ensures the nurse does not cause trauma to the canal
while achieving a clear view.
, 4. A patient presents with a suspicious skin lesion. Which characteristic following the ‘ABCDE’
rule would indicate a potential melanoma?
A. Border irregularity
B. Uniform light brown color
C. Diameter less than 4 mm
D. Symmetrical borders
Correct Answer: A
Expert Explanation: Border irregularity is a key warning sign in the assessment of skin
lesions for melanoma. The ABCDE rule stands for Asymmetry, Border irregularity, Color
variation, Diameter greater than 6mm, and Evolving shape or size. Any lesion exhibiting
these characteristics should be further evaluated by a specialist to rule out malignancy.
5. Which assessment technique is most appropriate for evaluating the presence of tactile
fremitus in the respiratory system?
A. Auscultation with the bell of the stethoscope
B. Inspection of thoracic expansion
C. Percussion of the intercostal spaces
D. Palpation using the ulnar surface of the hands
Correct Answer: D
Assessment Q&A with Rationale |
Rasmussen University
1. When assessing a patient’s skin turgor, where is the most reliable location to pinch the skin
on an elderly adult?
A. The back of the hand
B. Under the clavicle
C. The forearm
D. The abdomen
Correct Answer: B
Expert Explanation: In elderly patients, skin on the hands and arms loses elasticity,
making it an unreliable site for testing hydration. The skin under the clavicle or over the
sternum provides a more accurate assessment of turgor and hydration status. Tenting in
these areas indicates a significant loss of fluid or dehydration.
2. A nurse is performing a pupillary light reflex test. Which cranial nerve is primarily
responsible for the constrictive response to light?
A. Cranial Nerve III
B. Cranial Nerve II
C. Cranial Nerve IV
,D. Cranial Nerve VI
Correct Answer: A
Expert Explanation: Cranial Nerve III, also known as the Oculomotor nerve, is responsible
for pupil constriction and eyelid movement. While Cranial Nerve II (Optic) senses the light,
the motor response of constriction is carried out by CN III. Damage to this nerve can result
in a fixed or dilated pupil that does not react to light stimuli.
3. During an otoscopic examination of an adult, the nurse should pull the pinna in which
direction to straighten the ear canal?
A. Down and back
B. Up and back
C. Straight back
D. Up and forward
Correct Answer: B
Expert Explanation: For adult patients, the pinna is pulled up and back to align the ear
canal for better visualization of the tympanic membrane. In contrast, for children under the
age of three, the pinna is pulled down and back due to the different anatomical orientation
of their ear canals. This technique ensures the nurse does not cause trauma to the canal
while achieving a clear view.
, 4. A patient presents with a suspicious skin lesion. Which characteristic following the ‘ABCDE’
rule would indicate a potential melanoma?
A. Border irregularity
B. Uniform light brown color
C. Diameter less than 4 mm
D. Symmetrical borders
Correct Answer: A
Expert Explanation: Border irregularity is a key warning sign in the assessment of skin
lesions for melanoma. The ABCDE rule stands for Asymmetry, Border irregularity, Color
variation, Diameter greater than 6mm, and Evolving shape or size. Any lesion exhibiting
these characteristics should be further evaluated by a specialist to rule out malignancy.
5. Which assessment technique is most appropriate for evaluating the presence of tactile
fremitus in the respiratory system?
A. Auscultation with the bell of the stethoscope
B. Inspection of thoracic expansion
C. Percussion of the intercostal spaces
D. Palpation using the ulnar surface of the hands
Correct Answer: D
