NUR 3270/NUR3270 Exam 2 V2 | Comp
Health Assessment Q&A with Rationale |
William Paterson University
1. When assessing a patient’s skin turgor, where is the most reliable site for a nurse to check
an adult patient?
A. The back of the hand
B. Under the clavicle
C. The forearm
D. The abdomen
Answer: B
Rationale: The skin under the clavicle or over the sternum is the most reliable site for
assessing turgor in adults because it is less affected by age-related loss of elasticity. Turgor
is used to determine the patient’s hydration status by observing how quickly the skin
returns to its original position. A delay in returning to normal, or ‘tenting,’ is a sign of
dehydration.
2. In the ABCDE acronym for assessing skin lesions, what does the ‘E’ stand for?
A. Evolution
B. Exudate
C. Elevation
,D. Erythema
Answer: A
Rationale: Evolution refers to any change in the size, shape, color, or symptoms of a skin
lesion over time. This is a crucial diagnostic indicator for potential malignancy, such as
melanoma. Monitoring for evolution helps clinicians detect cancerous changes in their
earliest, most treatable stages.
3. The nurse is testing a patient’s pupils for accommodation. What response should the nurse
observe?
A. Constriction and convergence
B. Dilation and divergence
C. Constriction and divergence
D. Dilation and convergence
Answer: A
Rationale: Accommodation is tested by asking the patient to focus on a distant object and
then shift their gaze to a near object. The nurse should observe pupillary constriction and
the inward movement (convergence) of the eyes. This response indicates the eyes are
adjusting correctly to changes in focal distance.
4. A patient is being tested for visual acuity using a Snellen chart. The results are 20/40. What
does this indicate?
A. The patient can see at 40 feet what a normal person sees at 20 feet.
, B. The patient can see at 20 feet what a normal person sees at 40 feet.
C. The patient is legally blind in that specific eye.
D. The patient’s vision is twice as good as normal vision.
Answer: B
Rationale: The top number of the Snellen result represents the distance the patient is
standing from the chart, which is typically 20 feet. The bottom number represents the
distance at which a person with normal vision could read that same line. Therefore, 20/40
vision means the patient has poorer-than-average visual acuity.
5. When inspecting the tympanic membrane with an otoscope, what is considered a normal
finding?
A. Pearly gray and translucent membrane
B. Red and bulging membrane
C. Yellow or amber colored membrane
D. White, opaque, and thickened membrane
Answer: A
Rationale: A healthy tympanic membrane (eardrum) should appear pearly gray,
translucent, and slightly concave. The cone of light, which is a reflection of the otoscope
light, should be visible in the anterior-inferior quadrant. Any other colors, such as redness
or yellowing, suggest infection or fluid accumulation in the middle ear.
Health Assessment Q&A with Rationale |
William Paterson University
1. When assessing a patient’s skin turgor, where is the most reliable site for a nurse to check
an adult patient?
A. The back of the hand
B. Under the clavicle
C. The forearm
D. The abdomen
Answer: B
Rationale: The skin under the clavicle or over the sternum is the most reliable site for
assessing turgor in adults because it is less affected by age-related loss of elasticity. Turgor
is used to determine the patient’s hydration status by observing how quickly the skin
returns to its original position. A delay in returning to normal, or ‘tenting,’ is a sign of
dehydration.
2. In the ABCDE acronym for assessing skin lesions, what does the ‘E’ stand for?
A. Evolution
B. Exudate
C. Elevation
,D. Erythema
Answer: A
Rationale: Evolution refers to any change in the size, shape, color, or symptoms of a skin
lesion over time. This is a crucial diagnostic indicator for potential malignancy, such as
melanoma. Monitoring for evolution helps clinicians detect cancerous changes in their
earliest, most treatable stages.
3. The nurse is testing a patient’s pupils for accommodation. What response should the nurse
observe?
A. Constriction and convergence
B. Dilation and divergence
C. Constriction and divergence
D. Dilation and convergence
Answer: A
Rationale: Accommodation is tested by asking the patient to focus on a distant object and
then shift their gaze to a near object. The nurse should observe pupillary constriction and
the inward movement (convergence) of the eyes. This response indicates the eyes are
adjusting correctly to changes in focal distance.
4. A patient is being tested for visual acuity using a Snellen chart. The results are 20/40. What
does this indicate?
A. The patient can see at 40 feet what a normal person sees at 20 feet.
, B. The patient can see at 20 feet what a normal person sees at 40 feet.
C. The patient is legally blind in that specific eye.
D. The patient’s vision is twice as good as normal vision.
Answer: B
Rationale: The top number of the Snellen result represents the distance the patient is
standing from the chart, which is typically 20 feet. The bottom number represents the
distance at which a person with normal vision could read that same line. Therefore, 20/40
vision means the patient has poorer-than-average visual acuity.
5. When inspecting the tympanic membrane with an otoscope, what is considered a normal
finding?
A. Pearly gray and translucent membrane
B. Red and bulging membrane
C. Yellow or amber colored membrane
D. White, opaque, and thickened membrane
Answer: A
Rationale: A healthy tympanic membrane (eardrum) should appear pearly gray,
translucent, and slightly concave. The cone of light, which is a reflection of the otoscope
light, should be visible in the anterior-inferior quadrant. Any other colors, such as redness
or yellowing, suggest infection or fluid accumulation in the middle ear.
