NUR 2092/NUR2092 Exam 2 V1 | Health
Assessment Q&A with Rationale |
Rasmussen University
1. When assessing the skin for possible melanoma, which ‘B’ in the ABCDE mnemonic should
the nurse focus on?
A. Blood supply
B. Brightness of color
C. Bilateral symmetry
D. Border irregularity
Answer: D
Rationale: The ABCDE mnemonic is a tool used by healthcare providers to screen for
melanoma. The ‘B’ specifically stands for border irregularity, which refers to edges that are
notched, ragged, or blurred. Recognizing these characteristics is vital because benign moles
typically have smooth, even borders.
2. During a respiratory assessment, the nurse notes a 1:1 anteroposterior-to-transverse
diameter. How should this be documented?
A. Pectus excavatum
B. Normal findings
C. Barrel chest
,D. Scoliosis
Answer: C
Rationale: A barrel chest is characterized by an equal 1:1 ratio between the
anteroposterior and transverse diameters. This finding is commonly associated with
chronic obstructive pulmonary disease (COPD) due to hyperinflation of the lungs. In a
healthy adult, the ratio is typically 1:2 or 5:7.
3. The nurse is palpating the cervical lymph nodes. Which finding would be considered
normal in a healthy adult?
A. Nodes are non-palpable or small and mobile
B. Nodes are tender and warm
C. Nodes are large and fixed
D. Nodes are matted together
Answer: A
Rationale: In healthy adults, lymph nodes are usually not palpable. If they are palpable,
they should be small, mobile, discrete, and non-tender. Fixed, hard, or matted nodes are
abnormal findings that may indicate malignancy or infection.
4. Which heart sound is produced by the closure of the semilunar valves (aortic and
pulmonic)?
A. S2
, B. S1
C. S3
D. S4
Answer: A
Rationale: The S2 heart sound, often described as ‘dub’, signifies the end of systole. It is
caused by the closure of the semilunar valves, which include the aortic and pulmonic
valves. S1 occurs at the beginning of systole and is caused by the closure of the AV valves.
5. To assess for jaundice in a dark-skinned patient, where is the most reliable place for the
nurse to look?
A. The dorsal surface of the hand
B. The abdomen
C. The sclera and hard palate
D. The nail beds
Answer: C
Rationale: In dark-skinned individuals, jaundice is best assessed in the sclera and the hard
palate of the mouth. The yellow pigmentation of jaundice is often masked by natural skin
pigment in other areas. It is important to look where the yellow color of bilirubin is most
visible against lighter tissues.
Assessment Q&A with Rationale |
Rasmussen University
1. When assessing the skin for possible melanoma, which ‘B’ in the ABCDE mnemonic should
the nurse focus on?
A. Blood supply
B. Brightness of color
C. Bilateral symmetry
D. Border irregularity
Answer: D
Rationale: The ABCDE mnemonic is a tool used by healthcare providers to screen for
melanoma. The ‘B’ specifically stands for border irregularity, which refers to edges that are
notched, ragged, or blurred. Recognizing these characteristics is vital because benign moles
typically have smooth, even borders.
2. During a respiratory assessment, the nurse notes a 1:1 anteroposterior-to-transverse
diameter. How should this be documented?
A. Pectus excavatum
B. Normal findings
C. Barrel chest
,D. Scoliosis
Answer: C
Rationale: A barrel chest is characterized by an equal 1:1 ratio between the
anteroposterior and transverse diameters. This finding is commonly associated with
chronic obstructive pulmonary disease (COPD) due to hyperinflation of the lungs. In a
healthy adult, the ratio is typically 1:2 or 5:7.
3. The nurse is palpating the cervical lymph nodes. Which finding would be considered
normal in a healthy adult?
A. Nodes are non-palpable or small and mobile
B. Nodes are tender and warm
C. Nodes are large and fixed
D. Nodes are matted together
Answer: A
Rationale: In healthy adults, lymph nodes are usually not palpable. If they are palpable,
they should be small, mobile, discrete, and non-tender. Fixed, hard, or matted nodes are
abnormal findings that may indicate malignancy or infection.
4. Which heart sound is produced by the closure of the semilunar valves (aortic and
pulmonic)?
A. S2
, B. S1
C. S3
D. S4
Answer: A
Rationale: The S2 heart sound, often described as ‘dub’, signifies the end of systole. It is
caused by the closure of the semilunar valves, which include the aortic and pulmonic
valves. S1 occurs at the beginning of systole and is caused by the closure of the AV valves.
5. To assess for jaundice in a dark-skinned patient, where is the most reliable place for the
nurse to look?
A. The dorsal surface of the hand
B. The abdomen
C. The sclera and hard palate
D. The nail beds
Answer: C
Rationale: In dark-skinned individuals, jaundice is best assessed in the sclera and the hard
palate of the mouth. The yellow pigmentation of jaundice is often masked by natural skin
pigment in other areas. It is important to look where the yellow color of bilirubin is most
visible against lighter tissues.
