NUR 216 – HEALTH ASSESSMENT EXAM 2 WITH CORRECTLY ANSWERED QUESTIONS
GRADED A+ 2026/2027.
Question 1
When should a nurse perform a primary skin assessment on a patient to best identify immediate
risks and establish a baseline for care?
A) Only when the patient explicitly complains of a rash
B) Within 24 hours of the patient being discharged
C) Immediately upon the patient’s admission to the healthcare facility
D) During the first physical therapy session
E) Only if the patient has a history of skin cancer
Correct Answer: C) Immediately upon the patient’s admission to the healthcare facility
Rationale: Performing a skin assessment upon admission is critical for establishing a clinical
baseline. This allows the nurse to document any pre-existing lesions, pressure injuries, or
abnormalities, ensuring that any hospital-acquired skin issues are identified and addressed
promptly.
Question 2
A nurse is assessing a patient’s subjective complaints regarding a new skin lesion. Which
framework should the nurse utilize to gather comprehensive data about the symptom's onset,
triggers, and quality?
A) RICE method
B) ABCDE method
C) OPQRST method
D) Glasgow Coma Scale
E) Braden Scale
Correct Answer: C) OPQRST Method
Rationale: The OPQRST (Onset, Provocation, Quality, Radiation, Severity, Time) method is
a standardized mnemonic used to explore the characteristics of a symptom. In skin
assessment, it helps determine when the lesion appeared, what makes it worse, what it feels
like, and if it has changed over time.
Question 3
While performing a physical assessment, which of the following findings requires immediate
nursing intervention and takes priority over all other vital sign abnormalities?
A) A blood pressure of 145/92 mmHg
B) A heart rate of 102 beats per minute
C) The presence of angioedema
D) A temperature of 100.2°F
E) A respiratory rate of 22 breaths per minute
Correct Answer: C) Angioedema
Rationale: Angioedema involves deep swelling of the subcutaneous tissues, often around the
, 2
face and airway. Because it can rapidly progress to airway obstruction, it is a life-
threatening emergency that takes precedence over non-critical abnormal vital signs.
Question 4
A post-surgical patient presents with an O2 saturation of 89%, BP of 140/90, and pain rated 2/10.
The patient reports a new feeling of "tightness" in their chest. Which finding requires the most
immediate follow-up?
A) The blood pressure of 140/90
B) The oxygen saturation of 89%
C) The pain rating of 2/10
D) New feeling of tightness in the chest
E) The surgical incision site
Correct Answer: D) New feeling of tightness in their chest
Rationale: While an O2 saturation of 89% is concerning, a new report of chest tightness is a
hallmark symptom of potential myocardial ischemia or pulmonary embolism. New-onset
chest symptoms are always prioritized as they indicate an acute, potentially life-threatening
cardiac or respiratory event.
Question 5
When managing a clinical workload, the nurse understands that the primary focus of clinical
prioritization should always be:
A) Routine documentation and charting
B) An active, acute problem
C) Chronic conditions that have been stable for years
D) Discharge paperwork for stable patients
E) Patient education for future lifestyle changes
Correct Answer: B) An active, acute problem
Rationale: Acute problems (such as sudden respiratory distress or chest pain) represent
immediate threats to patient stability. Clinical prioritization follows the ABC (Airway,
Breathing, Circulation) framework, placing active, unstable issues above routine or chronic
care tasks.
Question 6
Which standardized tool is specifically utilized by nurses to document a patient’s risk for
developing pressure injuries?
A) Norton Scale
B) Glasgow Coma Scale
C) Braden Scale
D) Morse Fall Scale
E) FLACC Scale
Correct Answer: C) Braden Scale
, 3
Rationale: The Braden Scale assesses six risk factors: sensory perception, moisture, activity,
mobility, nutrition, and friction/shear. A lower score indicates a higher risk for pressure
injury development, allowing for targeted preventative interventions.
Question 7
During a skin assessment, which of the following combinations of factors indicates a
significantly higher risk for skin breakdown?
A) Dry skin and high protein intake
B) Frequent repositioning and intact skin
C) Moisture and existing lesions
D) Use of moisturizing lotions and adequate hydration
E) Darker skin tone and young age
Correct Answer: C) Moisture and existing lesions
Rationale: Moisture (from perspiration or incontinence) softens the skin (maceration),
making it more susceptible to breakdown. Existing lesions indicate that the skin’s integrity
is already compromised, further increasing the risk of larger pressure injuries.
Question 8
When assessing a patient with a dark skin tone for signs of cyanosis, which area provides the
most reliable and accurate clinical evidence?
A) The nail beds
B) The skin of the forearms
C) The mucous membranes
D) The soles of the feet
E) The earlobes
Correct Answer: C) Mucous membranes
Rationale: In patients with increased skin pigmentation, traditional signs of cyanosis (blue
tint) may be difficult to see on the skin surface. The mucous membranes, such as the oral
mucosa and conjunctiva, lack this pigmentation and are the most reliable sites to detect
central cyanosis.
Question 9
A nurse is educating a patient on how to evaluate changes in moles that may indicate melanoma.
Which standardized methodology should be taught?
A) OPQRST Method
B) ABCDE Method
C) PERRLA Method
D) PQRST Method
E) IPPA Method
Correct Answer: B) ABCDE Method
Rationale: The ABCDE acronym stands for Asymmetry, Border (irregular), Color
GRADED A+ 2026/2027.
Question 1
When should a nurse perform a primary skin assessment on a patient to best identify immediate
risks and establish a baseline for care?
A) Only when the patient explicitly complains of a rash
B) Within 24 hours of the patient being discharged
C) Immediately upon the patient’s admission to the healthcare facility
D) During the first physical therapy session
E) Only if the patient has a history of skin cancer
Correct Answer: C) Immediately upon the patient’s admission to the healthcare facility
Rationale: Performing a skin assessment upon admission is critical for establishing a clinical
baseline. This allows the nurse to document any pre-existing lesions, pressure injuries, or
abnormalities, ensuring that any hospital-acquired skin issues are identified and addressed
promptly.
Question 2
A nurse is assessing a patient’s subjective complaints regarding a new skin lesion. Which
framework should the nurse utilize to gather comprehensive data about the symptom's onset,
triggers, and quality?
A) RICE method
B) ABCDE method
C) OPQRST method
D) Glasgow Coma Scale
E) Braden Scale
Correct Answer: C) OPQRST Method
Rationale: The OPQRST (Onset, Provocation, Quality, Radiation, Severity, Time) method is
a standardized mnemonic used to explore the characteristics of a symptom. In skin
assessment, it helps determine when the lesion appeared, what makes it worse, what it feels
like, and if it has changed over time.
Question 3
While performing a physical assessment, which of the following findings requires immediate
nursing intervention and takes priority over all other vital sign abnormalities?
A) A blood pressure of 145/92 mmHg
B) A heart rate of 102 beats per minute
C) The presence of angioedema
D) A temperature of 100.2°F
E) A respiratory rate of 22 breaths per minute
Correct Answer: C) Angioedema
Rationale: Angioedema involves deep swelling of the subcutaneous tissues, often around the
, 2
face and airway. Because it can rapidly progress to airway obstruction, it is a life-
threatening emergency that takes precedence over non-critical abnormal vital signs.
Question 4
A post-surgical patient presents with an O2 saturation of 89%, BP of 140/90, and pain rated 2/10.
The patient reports a new feeling of "tightness" in their chest. Which finding requires the most
immediate follow-up?
A) The blood pressure of 140/90
B) The oxygen saturation of 89%
C) The pain rating of 2/10
D) New feeling of tightness in the chest
E) The surgical incision site
Correct Answer: D) New feeling of tightness in their chest
Rationale: While an O2 saturation of 89% is concerning, a new report of chest tightness is a
hallmark symptom of potential myocardial ischemia or pulmonary embolism. New-onset
chest symptoms are always prioritized as they indicate an acute, potentially life-threatening
cardiac or respiratory event.
Question 5
When managing a clinical workload, the nurse understands that the primary focus of clinical
prioritization should always be:
A) Routine documentation and charting
B) An active, acute problem
C) Chronic conditions that have been stable for years
D) Discharge paperwork for stable patients
E) Patient education for future lifestyle changes
Correct Answer: B) An active, acute problem
Rationale: Acute problems (such as sudden respiratory distress or chest pain) represent
immediate threats to patient stability. Clinical prioritization follows the ABC (Airway,
Breathing, Circulation) framework, placing active, unstable issues above routine or chronic
care tasks.
Question 6
Which standardized tool is specifically utilized by nurses to document a patient’s risk for
developing pressure injuries?
A) Norton Scale
B) Glasgow Coma Scale
C) Braden Scale
D) Morse Fall Scale
E) FLACC Scale
Correct Answer: C) Braden Scale
, 3
Rationale: The Braden Scale assesses six risk factors: sensory perception, moisture, activity,
mobility, nutrition, and friction/shear. A lower score indicates a higher risk for pressure
injury development, allowing for targeted preventative interventions.
Question 7
During a skin assessment, which of the following combinations of factors indicates a
significantly higher risk for skin breakdown?
A) Dry skin and high protein intake
B) Frequent repositioning and intact skin
C) Moisture and existing lesions
D) Use of moisturizing lotions and adequate hydration
E) Darker skin tone and young age
Correct Answer: C) Moisture and existing lesions
Rationale: Moisture (from perspiration or incontinence) softens the skin (maceration),
making it more susceptible to breakdown. Existing lesions indicate that the skin’s integrity
is already compromised, further increasing the risk of larger pressure injuries.
Question 8
When assessing a patient with a dark skin tone for signs of cyanosis, which area provides the
most reliable and accurate clinical evidence?
A) The nail beds
B) The skin of the forearms
C) The mucous membranes
D) The soles of the feet
E) The earlobes
Correct Answer: C) Mucous membranes
Rationale: In patients with increased skin pigmentation, traditional signs of cyanosis (blue
tint) may be difficult to see on the skin surface. The mucous membranes, such as the oral
mucosa and conjunctiva, lack this pigmentation and are the most reliable sites to detect
central cyanosis.
Question 9
A nurse is educating a patient on how to evaluate changes in moles that may indicate melanoma.
Which standardized methodology should be taught?
A) OPQRST Method
B) ABCDE Method
C) PERRLA Method
D) PQRST Method
E) IPPA Method
Correct Answer: B) ABCDE Method
Rationale: The ABCDE acronym stands for Asymmetry, Border (irregular), Color
